Interim Considerations for Testing for K-12 School Administrators and Public Health Officials

Interim Considerations for Testing for K-12 School Administrators and Public Health Officials

These interim considerations are based on what is currently known about COVID-19 as of the date of posting, October 11, 2020. These considerations are for testing in school settings and are intended for K-12 school administrators working in collaboration with their state, tribal, local, and territorial (STLT) public health officials. While these considerations were developed with public schools, including charter schools, in mind, private schools may also find these considerations useful.

These considerations are meant to supplement—not replace—any federal, state, tribal, territorial, or local health and safety or privacy laws, rules, regulations, and policies with which schools must comply. The decision to implement testing in schools should be guided by what is feasible, practical, and acceptable. If antigen testing is used, it should be tailored to each community’s needs.

This considerations document does not dictate the determination of payment decisions or insurance coverage of such testing, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency. U.S. Centers for Disease Control and Prevention (CDC) has no regulatory authority over testing; therefore, this document is intended to assist STLT public health officials and K-12 school officials in making decisions rather than establishing any regulatory requirements.

CDC will update these considerations as needed and as additional information becomes available. Please check CDC website periodically for updated interim guidance.

With the increased availability of tests, these considerations are intended to provide guidance on the appropriate use of testing for SARS-CoV-2 (the virus that causes COVID-19) in K-12 schools for surveillance, diagnosis, screening, or outbreak response. Schools can help protect students and their families, teachers, staff, and the broader community and slow the spread of COVID-19. Testing to diagnose COVID-19 is part of a comprehensive strategy and should be used in conjunction with promoting behaviors that reduce spread (e.g., mask use, social distancing, hand hygiene); maintaining healthy environments (e.g., cleaning and disinfection, ventilation); maintaining healthy operations (e.g., scheduling, virtual learning, class sizes); and preparing for when someone gets sick. If an outbreak occurs, schools should immediately notify STLT public health officials. STLT officials will then work closely with school administrators to scale up testing, identify contacts and initiate contact tracing, and determine who will need to be quarantined and isolated.

Schools should work with STLT public health officials to decide and how to use testing. K-12 schools operated by the federal government (e.g., for Department of Defense Education Activity (DoDEA), which operates K-12 schools for DoD Dependents) should collaborate with federal health officials. In addition to state and local laws, school administrators should follow guidance from the Equal Employment Opportunity Commissionexternal icon when offering testing to faculty, staff, and students who are employed by the K-12 school. Schools also should follow guidance from the U.S. Department of Education on the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA)external icon and FERPA and COVID-19external icon and their applicability to students and COVID-19 contact tracing and testing.

Types of tests to identify SARS-CoV-2, the virus that causes COVID-19

Table 1 summarizes the main types and characteristics of tests used to diagnose current SARS-CoV-2 infection, the virus that causes COVID-19. Additional information can be found on CDC’s SARS-CoV-2 testing pages. Throughout this document, “testing” refers to viral testing for potential infection. Tests used to show past SARS-CoV-2 infection (i.e., antibody tests) are not included in this document. CDC does not currently recommend using antibody testing as the sole basis for diagnosis of current infection. For more information the Food and Drug Administration (FDA) has provided FAQs on testing for COVID-19external icon.

Table 1: Types of COVID-19 tests currently available to diagnose current infection
  Viral Tests
Molecular Tests Antigen Tests
How is the sample taken? Nasal or throat swab (most tests); saliva or sputum test (a few tests) Nasal­­­­­­­­­­­­­­­ or throat swab
What does it test? Diagnose current SARS-CoV-2 infection by detecting viral genetic material (Nucleic acid amplification tests (NAAT), including real-time reverse-transcriptase Polymerase chain reaction (RT-PCR). Diagnose current SARS-CoV-2 infection by detecting viral proteins.
How are the results used? Help public health officials identify and recommend isolation for people with active infection in order to minimize COVID-19 transmission. Help public health officials identify and recommend isolation for people with active infection in order to minimize COVID-19 transmission.
Who administers test? Nasal or throat swab can be self-collected in the company of a health professional or can be collected by a health professional. Test must be performed by trained staff in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory or point-of-care testing site operating under certificate of waiver. Test must be administered by trained staff associated with CLIA-certified laboratory or point-of-care site that has a certificate of waiver.
Other information Considered the gold standard for COVID-19 detection and are typically performed in a specialized laboratory. A few molecular tests have been authorized for and have data supporting use in asymptomatic individuals.

Some molecular tests can be performed at or near the point of care.

May be more likely to miss a current infection than molecular tests such as RT-PCR.

Currently, there are not enough data to know if using antigen tests is effective for people with COVID-19 who do not have symptoms.

Performed at or near the point of care.

 

How long does it take to get results? 1 to 3 days Approximately 15 minutes

*Table adapted from U.S Food & Drug Administrationexternal icon Table

School-based testing should NEVER be conducted without consent from a parent or legal guardian (for minor students) or from the individual him or herself (for adults). Assent may also be considered for minor students.

When testing might be performed

Schools can play an important role in assisting public health officials in identifying teachers, staff, or students who have COVID-19 symptoms or who had recent close contact with someone with COVID-19. If the school is experiencing an outbreak, the school should immediately notify public health officials and collaborate to facilitate increased testing and contact tracing, as necessary. School administrators working in close collaboration with public health officials might choose to test students, teachers, or staff for purposes of surveillance, diagnosis, screening, or in the context of an outbreak and public health consultation.

  • School-based testing may be considered for:
    • People in a school setting who show signs or symptoms consistent with COVID-19 while at school.
    • Schools in a community where public health officials are recommending expanded testing on a voluntary basis including testing of a sample of asymptomatic individuals, especially in areas of moderate to high community transmission.
  • Public health officials may consider providing testing for people who, for example:
    • Have a recent known or suspected exposure to a person with laboratory-confirmed COVID-19.
    • Have been asked or referred to get testing by their healthcare provider or health department.
    • Are part of a cohort for whom testing is recommended (e.g., in the context of an outbreak). 

When testing is not recommended?

If a school is implementing a testing strategy, testing should be offered on a voluntary basis.  It is unethical and illegal to test someone who does not want to be tested, including students whose parents or guardians do not want them to be tested. It is not recommended to retest individuals who have tested positive and do not have symptoms for COVID-19 for up to 3 months from their last positive test. Data currently suggest that some individuals test persistently positive due to residual virus material but are unlikely to be infectious. Parents or guardians may request documentation from their health care provider to indicate the date and type of the student’s most recent COVID-19 test.

Which schools and persons should be prioritized for school-based testing?

Health departments and school districts can work together to develop a strategy for prioritizing K-12 schools, depending on resources and goals, for school-based testing.

There are three levels of decision-making when it comes to selecting school-based testing:

  • Which schools?
  • Which persons in those schools?
  • Which strategies?

Which schools?

Schools that have opened for any in-person classes (including hybrid, which includes combination of in-person and virtual classes) can benefit from developing a testing strategy. CDC’s Indicators for Dynamic School Decision-Making can be used to determine which schools may provide the best settings for school-based testing.

Schools in communities disproportionately affected or that lack access to testing

Public health officials and school administrators may consider placing a higher priority for testing in schools that serve populations experiencing a disproportionate burden of COVID-19 cases or severe disease. These may include:

  • Schools with moderate or large proportions of racial and ethnic groups that have experienced higher rates of COVID-19 cases relative to population size.
  • Schools in geographic areas with limited access to testing due to distance or lack of availability of testing.

Schools in communities with moderate, higher, and highest risk of transmission

The decision to initiate a school-based testing strategy among students, teachers, and staff should be made in consultation with the local health department. CDC recommends taking into consideration the level of community transmission and implementation of mitigation strategies when deciding on school-based testing. Testing in schools located in communities at moderate to highest risk may provide the maximum balance of testing efficiency.

Schools with an active outbreak  

Classrooms or schools experiencing an active outbreak may temporarily close for in-person learning. The local health department may facilitate testing for students, teachers, and staff who are in schools with an active outbreak. The health department will also conduct contact tracing in these situations. Schools can assist by providing information to identify close contacts (e.g., class rosters, seating charts, and student emergency contact information). Health departments can use a tiered approach (Table 2) in an outbreak setting to determine which close contacts and other potentially exposed persons could be tested and either isolated or quarantined.

Which persons?

Once public health officials determine the school’s risk category, public health officials working in collaboration with school administrators can prioritize which staff, teachers, and students should be offered school-based testing. Persons with symptoms for COVID-19 and close contacts of confirmed or probable COVID-19 patients should be considered the priority for testing. Asymptomatic staff, teachers and students who are not close contacts should also be considered for testing in schools where the risk of transmission is moderate to high. Table 2 shows how to prioritize testing for close contacts using a tiered approach. Schools should work collaboratively with public health officials to consider conduct testing and selection of persons for school-based testing in all levels of the suggested hierarchy.

Students, teachers, and staff with symptoms

Individuals showing symptoms of COVID-19 in schools should be prioritized for testing. People with COVID-19 can report a wide range of symptoms ranging from mild symptoms to severe illness. Symptoms may appear 2 to 14 days after exposure to the virus that causes COVID-19. Students, teachers, and staff members are encouraged to monitor themselves for symptoms. According to CDC guidance, symptoms may include:

  • fever or chills
  • cough
  • shortness of breath or difficulty breathing
  • muscle or body aches
  • headache
  • new loss of taste or smell
  • sore throat
  • congestion or runny nose
  • nausea or vomiting or diarrhea

Hierarchy of testing for SARS-CoV-2 testing

Hierarchy for selection of persons for testing in schools can be as follows

  1. Persons with symptoms of COVID-19
  2. Persons who have had contact with someone with COVID-19 (see Table 2 for defining and identifying contacts)
  3. All students, faculty, and staff with possible exposure in the context of outbreak settings (as described in Table 2)

Defining and identifying close contacts
Table 2 provides an overview strategy for defining and identifying close contacts of individuals of positive COVID-19 cases. It describes tiers of criteria for determining close contacts. In collaboration with local public health officials, the definitions for tiers should be adapted to reflect the specific school setting and to be consistent with the health department’s contact tracing strategies.

Tiered approach for SARS-CoV-2 testing of persons with possible exposure in the context of a school Screening for symptoms and testing of symptomatic persons should continue in addition to the additional testing outlined below.

  • Students, teachers, and staff in Tier1 (Table 2), who have a known close contact (within 6 feet of an infected person for at least 15 minutes) with confirmed or probable COVID-19 should be tested and quarantined as soon as possible to reduce the risk of further transmission. All quarantined individuals should follow existing guidance and stay home and monitor their health for 14 days after last contact with a person who has COVID-19. If possible, stay away from others, especially people who are at higher risk for getting very sick from COVID-19.
  • Students, teachers, and staff in Tier 2 and Tier 3 (Table 2): Testing may be considered for these individuals based on recommendations from their healthcare provider and assessment of exposure risk or a positive symptom screen from a reputable COVID-19 screener, such as CDC’s Coronavirus Self-Checker. Students, teachers, and staff in Tier 2 and Tier 3 should also be considered for testing if during contact tracing an individual is considered as a potential contact or if an individual has symptoms. When determining sequencing for testing of Tier 2 and Tier 3 individuals, schools and public health officials may consider prioritizing teachers and staff over students given the higher risk for severe disease outcomes among adults.
Table 2: Tiered approach and criteria for determination of contacts for testing
Tier 1

Close contacts

Highest risk of transmission*

Students, teachers, and staff who were less than 6 feet apart from the individual with COVID-19 for at least 15 minutes or more beginning 2 days before the individual with COVID-19 became symptomatic (or, for asymptomatic individuals, 2 days prior to specimen collection) until the time of isolation.** Schools should consider the following example settings in determining close contacts:
  • Classrooms
  • Lunchrooms
  • Athletic teams and other extracurricular activities
  • After-school care and other events
Tier 2

Potential contacts

Next highest risk of transmission

Students, teachers, and staff in the same classroom/cohort/pod as the person with COVID-19 who always kept 6 feet distance between persons. For example, this includes individuals in the following scenarios:
  • Students, teachers, or staff in the same hallway, but not sharing a classroom or bathroom.
  • Students who took the same bus but were farther than 6 feet apart from other riders at the same time as a person with COVID-19.
Tier 3

Potentially exposed individuals

Lowest risk of transmission

Students, teachers, and staff who shared a common space (e.g., teacher’s lounge, library) and were not using the space at the same time as the person with COVID-19, but where short duration exposure to those with confirmed COVID-19 cannot be definitively ruled out. For example, this includes:
  • Students, teachers, and staff who are in-person at the school on a different schedule and in different rooms than the individual with confirmed COVID-19, but exposure cannot be definitively ruled out.

Which strategies?

Health departments and school districts can work together to develop a strategy for prioritizing K-12 schools, depending on resources and goals, for school-based testing. Implementation of mitigation strategies (e.g., social distancing, masks, hand hygiene, enhanced cleaning and disinfection) should be implemented with all of the various testing strategies.

Testing people with symptoms: Schools should advise teachers, staff, and students to stay home if they are sick or if they have been exposed to COVID-19. Encourage these individuals to talk to their healthcare provider about getting testing for COVID-19 in a healthcare or public health facility.

If a teacher, staff, or student becomes sick at school or reports a new COVID-19 diagnosis, schools should follow the steps of the new COVID-19 Diagnosis flowchart on what to do next. This includes notifying a student’s parent or guardian, and initiating testing strategies.

  • In some schools, school-based healthcare professionals (e.g., school nurses) may perform COVID-19 antigen testing in school-based health centers if they receive a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiverexternal icon. It is important schools-based healthcare professionals have access to, and training on the proper use of personal protective equipment (PPE).
  • Not every school or school-based healthcare professional will have the resources or training to conduct testing. Public health officials should work with schools to help link students and their families, teachers, and staff to other opportunities for testing in their community.

Schools can provide options to separate students with COVID-19 symptoms or suspected or confirmed COVID-19 diagnoses by, for example placing students in isolation room/areas until transportation can be arranged to send them home or seek emergency medical attention.

If a COVID-19 diagnosis is confirmed, schools can assist public health officials in determining which close contacts and other potentially exposed persons could be tested and either isolated for 10 days (if they have COVID-19) or quarantined for 14 days (if they are a close contact without symptoms or a negative test result; see Table 2).

Note: CDC’s Coronavirus Self-Checker is an interactive clinical assessment tool that will assist individuals aged 13 years and older, and parents and caregivers of children aged 2 to 12 years, in deciding when to seek testing or medical care if they suspect they or someone they know has contracted COVID-19 or has come into close contact with someone who has COVID-19.

Testing people without symptoms who are close contacts of positive COVID-19 cases: Schools can assist by providing information, where appropriate, to identify close contacts (e.g., class rosters, seating charts, and information to facilitate outreach to contacts). CDC defines close contacts as those within 6 feet of someone with known or suspected COVID-19 for at least 15 minutes, irrespective of whether the contact was wearing a mask or PPE (see Table 3).  Additional factors to consider include proximity, the duration of exposure (longer exposure time likely increases exposure risk), and whether the exposure was to a person with symptoms (e.g., coughing likely increases exposure risk).  The local health department will facilitate contact tracing and testing for close contacts in coordination with parents or guardians and schools.

All persons who are identified as close contacts need to quarantine for 14 days, even if screening test results are negative, because they can still develop COVID-19 for up to 14 days after being exposed. Quarantine helps prevent spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling symptoms. Close contacts who are in quarantine who develop symptoms should be re-tested.

Testing of persons in an outbreak setting: Classrooms or schools may temporarily suspend in-person instruction when experiencing an active outbreak. The local health department will facilitate contact tracing and testing for schools with an active outbreak. Schools can assist by providing information to identify close contact (e.g., class rosters, seating charts, and information to facilitate outreach to contacts). Persons who are close contacts of anyone confirmed or suspected of having COVID-19 should be quarantined for 14 days from their last contact. Schools in an outbreak setting can use a tiered approach (see Table 3) to determine which close contacts and other potentially exposed persons should be tested and either isolated or quarantined.  

Other testing strategies:

  • Repeat testing and/or expanded testing of teachers, staff, and students: In schools where the risk of transmission is moderate to high, public health officials working collaboratively with school administrators can determine the appropriateness of offering repeat testing to randomly-selected asymptomatic teachers, staff, and students at the school. Testing teachers and staff should be prioritized over students in any sampling strategy, and older students prioritized over younger students. Persons who have recovered from COVID-19 in the past 3 months should be excluded from random selection. Contact tracing should immediately begin if anyone tests positive for COVID-19. Close contacts of persons with confirmed or probable COVID-19 should be tested and either isolated for 10 days for those with COVID-19, or quarantined for 14 days.
  • Entry testing or universal one-time testing: It is not known if testing of all staff, teachers, and students at one point in time (referred to as entry testing or universal one-time testing) provides any additional reduction in virus transmission above the key mitigation strategies recommended for schools. Currently, CDC does not have specific recommendations for entry testing of all students, teachers, and staff. However, if infrastructure is in place, and resources are available, schools can serve as a venue for health departments to offer community-based testing to teachers, staff, students and potentially their family members.

How should schools report results of school-based testing?

Every COVID-19 testing site is required to report to the appropriate state or local health officials all diagnostic and screening tests performed. Schools that use antigen testing must apply for and receive a Clinical Laboratory Improvement Amendments (CLIA)external icon certificate of waiver, and report test results to state or local public health departments as mandated by the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

In addition, school administrators should notify staff, teachers, families and/or emergency contacts or legal guardians immediately of any case of COVID-19 while maintaining confidentiality in accordance with HIPAA,external icon ADAexternal icon, FERPApdf iconexternal icon, and other applicable laws and regulations. Notifications should be accessible for all students, faculty and staff, including those with disabilities or limited English proficiency (e.g., through use of interpreters or translated materials).

Challenges of school-based testing

These challenges must be considered carefully and addressed as part of plans for school-based testing developed in collaboration with public health officials.

  • Not every school system will have the resources or training (including the CLIA certificate of waiver mentioned above) to conduct school-based antigen testing. Public health officials should work with schools to help link students and their families, teachers, and staff to other opportunities for testing in their community.
  • School-based testing may require a high degree of coordination and information exchange among health departments, schools, and families.
  • There may also be legal factors to consider with onsite school-based testing regarding who will administer the tests, how tests will be paid for, and how results will be reported. Such legal factors include local or state laws defining the services school nurses and other school-based health professionals are permitted to provide.
  • The benefits of school-based testing need to be weighed against the costs, inconvenience, and feasibility of such programs to both schools and families.
  • Antigen tests usually provide results diagnosing an active SARS-CoV-2 infection faster than molecular tests, but antigen tests have a higher chance of missing an active infection even in symptomatic individuals and confirmatory molecular testing may be recommended. Although antigen tests have not be authorized for use in asymptomatic individuals, FDA and Centers for Medicare and Medicaid Services have allowed the use of these tests in situations where a rapid result is needed.

Considerations before starting ANY testing strategy

Before implementing testing in their schools, K-12 administrators should coordinate with public health officials to ensure there is support for this approach from students, parents, teachers, and staff and to put key elements in place:

  • Dedicated infrastructure and resources to support school-based testing.
  • CLIA certificate of waiver requirements to perform school-based testing.
  • Mechanism to report all testing results (both positive and negative) as required by the state or local public health department.
  • Plans for ensuring access to confirmatory molecular testing when needed through the state and local health department because sometimes antigen tests can give false positive results that represent errors and not true infections.
  • Ways to obtain parental consent for minor students and assent/consent for the students themselves.
  • Physical space to conduct testing safely and privately.
  • Ability to maintain confidentiality of results and protect student privacy.

If these conditions are not in place, schools may consider a referral-based testing strategy in collaboration with public health officials.

How can schools adequately plan for testing?

School Administrators considering testing should work with public health officials to address questions related to feasibility, logistics, and ethics of school-based testing, such as the ones listed in Table 3 below.

Table 3: Questions to consider for implementing mitigation strategies to reduce transmission of COVID-19
Readiness
  • Does a plan for implementing school-based testing and mitigation strategies exist?
  • Has the school made contact with public health officials and received consultation on the plan?
  • Have public health official and school administrators identified needs for adequate overall infrastructure to support the activity?
  • Have public health officials and school administrators ensured the schools obtained a CLIA certificate waiverpdf iconexternal icon?
  • Who will be responsible for developing a system to report both positive and negative results to the state or local public health department?
  • How will test results from schools be communicated to state health departments?
  • How many tests will be needed?
  • What training is needed for teachers and other school personnel regarding how to have conversations with parents about testing results?
  • Are school emergency contact lists up to date?
Collection of Specimens
  • Who will conduct the swabbing and testing?
  • Are there enough staff who are sufficiently trained in obtaining and storing specimens, how to protect themselves, and the proper use of personal protective equipment (PPE)?
  • Where will the specimen collection be performed?
  • When will specimens be collected?
  • What additional materials and supplies, including PPE, are needed? What quantities will be needed?
  • Where will the specimen collection and testing supplies, and collected specimens be stored, and temperature controlled?
  • What will be the protocols for cleaning and disinfection of the testing area and equipment?
  • How will used PPE and potential biohazard waste be disposed?
Ethics and Feasibility
  • Who will be tested and how often?
  • Will a testing rotation be established so that the same people are not tested every time a testing strategy randomly selects teachers, staff, or students?
  • Based on your supplies, how many tests can be performed over what time period?
  • When and how often should additional specimen collection supplies, and testing supplies and reagents, be obtained?
Consent and Harm Mitigation
  • What special considerations are needed to ensure students are still able to engage in learning while they are in quarantine or isolation?
  • What special considerations are needed for children with special healthcare needs or are immunocompromised?
  • What special considerations are needed for individuals with disabilities?
  • What special considerations are needed for individuals with limited English proficiency?
  • How will parent, guardian, or caregiver consent be obtained?
  • How will student consent or assent be obtained?
  • How and to whom will test results be provided?
  • Are multiple emergency contacts on file and current for each student?
  • Who will conduct contact tracing and notify people who are determined to be a close contact?
  • How will student and teacher privacy be addressed to minimize any potential harm?
  • How will stigma be addressed for students, teachers, or staff who are identified as having COVID-19 or having been tested for COVID-19?
  • How will potential stigma be addressed for those who choose not to be tested?
  • What is the emotional impact of testing on children?
  • How can fear of or resistance to testing be reduced?