key: cord-0326141-x39c8xm8
authors: Lee, S. S.; Weitz, M.; Ardlie, K.; Bantham, A.; Schuckel, M. F.; Goehringer, K.; Hogue, C.; Hosking, R.; Mortimer, K.; Saadat, A.; Seaman-Chandler, J.; Linas, B. P.; Ciaranello, A. L.
title: Resources Required for Implementation of SARS-CoV-2 Screening in Massachusetts K-12 Public Schools in Winter/Spring 2021
date: 2021-12-13
journal: nan
DOI: 10.1101/2021.12.10.21267568
sha: 822d8c94e234504c7c67364d61b713cf8ed8c413
doc_id: 326141
cord_uid: x39c8xm8

Importance CDC guidance emphasizes the importance of in-person education for students in grades kindergarten to 12 (K-12) during the COVID-19 pandemic. CDC encourages weekly SARS-CoV-2 testing of asymptomatic, unvaccinated students and staff ("screening") to reduce infection risk and provide data about in-school SARS-CoV-2 prevalence where community incidence is high. The financial costs of screening assays have been described, but the human resource requirements at the school and district level to implement a SARS-CoV-2 screening program are not well known. Objective To quantify the resources required to implement a screening program in K-12 schools. Design, Setting, and Participants A consortium of Massachusetts public K-12 schools was formed to implement and evaluate a range of SARS-CoV-2 screening approaches. Participating districts were surveyed weekly about their programs, including: type of assay used, individual vs. pooled screening, approaches to return of results and deconvolution (identification of positive individual specimens) of positive pools, number and type of personnel implementing the screening program, and hours spent on program implementation. Main Outcomes and Measures Costs, resource utilization Results In 21 participating districts, over 21 weeks from January to June 2021, the positivity rate was 0.0%-0.21% among students and 0.0%-0.13% among educators/staff, and 4 out of 21 (19%) districts had at least one classroom transition to remote learning at any point due to a positive case. The average weekly cost to implement a screening program, including assay and personnel costs, was $17.00 per person tested; this was $46.68 for individual screenings and $15.61 for pooled screenings. The total weekly costs by district ranged from $1,644-$93,486, and districts screened between 58 and 3,675 people per week. The reported number of personnel working per week ranged from 1-5 to >50, and the total number of hours worked by all personnel ranged from 5-10 to >50. Conclusion and Relevance The human resources required to implement SARS-CoV-2 screening in Massachusetts public K-12 schools were substantial. Where screening is recommended for the 2021-22 school year due to high COVID-19 incidence (e.g., where vaccination uptake is low and/or more infectious variants predominate), understanding the human resources required to implement screening will assist districts policymakers in planning.

The US Centers for Disease Control and Prevention (CDC) encourages in-person learning in kindergarten 76 149 We identified publicly available demographic and financial data for STSS districts participating in this 150 study and for all Massachusetts public school districts, including student enrollment; number of staff 151 employed; distribution of student gender and race/ethnicity; proportion of students who are 152 economically disadvantaged, defined by participation in one or more state-administered programs (e.g., 153

MassHealth or Supplemental Nutrition Assistance Program); proportions of students who are English 154 language learners or students with disabilities, as defined by DESE; 28 To estimate personnel costs, we made several simplifying assumptions necessitated by the structure of 165 the available survey data. The surveys reported the number of people required for program 166 implementation and the number of hours spent per week on implementation in strata (1-5, 5-10, etc.). 167

We used the midpoint of each stratum in the base-case analysis; in sensitivity analyses, we used the 168 lower and upper end of each stratum. We assumed that districts would only involve one of certain types 169 of personnel; we assumed equal distribution of personnel type among all remaining types of personnel 170 (e.g., school nurses, volunteers, etc.). We assumed that the total number of hours spent by all personnel 171 was equally distributed among all involved personnel. For example, if data indicated that all staff in a 172 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ;  district contributed 50 hours of labor, and there were 5 staff members, we assumed that each staff 173 member contributed 10 hours. We then calculated total (assay plus personnel) costs using data from each district's most recent week of 182

reporting. Due to the differences in assay cost for individual versus pooled screening, costs were 183 calculated separately for each week depending on whether a district provided pooled or individual tests 184 during that week. For weeks when pooled screeding was used, the cost of reflex testing (to deconvolute 185 and identify which individual specimen(s) in a positive pool are positive) was estimated from the 186 average number of positive pools and the average number of individuals included in a pool. We report 187 the average per-person total assay cost (initial assay plus reflex testing). We then used the number of 188 weeks in which either individual or pooled screening was offered to calculate a weighted average of the 189 total weekly costs. We repeated these analyses varying several key assumptions: using the minimum week for all districts, as well as for those offering individual or pooled screening and those participating 195 in the state-supported screening program or screening independently. 196 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint 

Of the 21 districts, at the time of the most recent reporting, 21 (100%) screened both educators/staff 218 and students ( Table 2 ). The majority (67%) screened students at all grade levels. More districts screened 219 weekly (20) than twice monthly (1), and more districts used pooled screening (20) than individual 220 screening (1). At the most recent reporting, twelve districts (57%) participated in the state-supported 221 screening program. Over the entire study period, 3 (14%) districts reported using individual screening 222 for a total of 12 district-weeks. All districts reported using pooled screening at some point during the 223 study period, for a total of 178 district-weeks. During the last reporting week, 1 district used individual 224 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ;  PCR screening to screen educators/staff and pooled screening for students, while 20 districts reported 225 using pooled screening for both educators/staff and students. 226 227

Educators/staff and students underwent a total of 271,246 tests. In the first week of the study period, 229 5,168 students from 5 districts (1,034 students per participating district) were offered screening, and 230 3,424 students from 5 districts (685 students per participating district) underwent screening (Figure 1 ). 231

These numbers increased to 4,137 students/district offered screening and 1,454 students/district 232 Table 3 for all districts, as well as for district-weeks of 244 individual and pooled PCR screening and of state-supported and non-state-supported programs. 245

Per person screened each week, average assay costs (including shipping and laboratory processing) were 246 $12.60, average personnel costs were $4.27, and average total costs (assay plus personnel) were $17.00. 247 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ;  In sensitivity analyses using the upper and lower bounds of reported personnel and time strata, average 248 higher total cost ($18.92 vs. $13.57). Of the 13 districts using in-school deconvolution, 7 (54%) reported 264 using Abbot SARS CoV-2 Binax NOW ™, 3 (23%) reported using PCR, and 3 (23%) reported using both 265

Abbot SARS CoV-2 Binax NOW ™ and PCR. Compared to Abbot SARS CoV-2 Binax NOW ™, PCR 266 deconvolution led to higher weekly per-person average assay cost ($13.13 vs. $6.59), lower personnel 267 cost ($2.45 vs. $6.57), and higher total costs ($15.58 vs. $13.34; not shown in Table 3 ). 268 269 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Massachusetts was one of the first states to implement state-wide pooled screenings in K-12 school 296 settings, thus serving as a model of the feasibility and advantages of the approach. 37,38 While our 297 analysis is limited to Massachusetts, these data provide useful information for schools across the U.S. 298

For example, several schools in Washington use rapid antigen tests for assurance testing, 39 a mandatory state-wide surveillance program, screening a sample of educators/staff and students in 303 schools in areas at higher risk of COVID-19 transmission. 45, 46 While the cost per person tested will differ 304 across settings, based on local labor markets and the cost of assays and reagents, this analysis provides 305 an estimate of both the resources needed to implement testing and the key drivers of cost. We 306 anticipate that the high-level findings -that testing is expensive and that the choice of testing model has 307 a large impact on cost considerations -will likely be generalizable to most K-12 school settings. 308 309 As schools weigh the trade-offs of implementing a screening program, they must consider a range of 310 benefits and costs. In our study, despite relatively high participation rates among students and staff 311 during a period of high community incidence before vaccination, the screening program identified only a 312 small number of SARS-CoV-2 infections (positivity rates of 0-0.13% for educators/staff and 0-0.21% for 313 students, consistent with overall positivity rates of 0.1% in the state-wide pooled screening program). 47 314

With an average pooled testing cost of $15.61/person and the highest observed weekly positivity rate 315 (0.16% among students and educators/staff), the cost per case identified from routine asymptomatic 316 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 13, 2021. ; https://doi.org/10.1101/2021.12.10.21267568 doi: medRxiv preprint testing in MA schools would be approximately $9,756. These data do not provide a measure of the 317 benefit of screening programs. In estimating those benefits and deciding whether routine testing 318 programs provide enough benefit to justify the cost, decision-makers must consider the value of test 319 results, both in terms of potential cases averted (which were few in this study), and also in terms of real-320 time, locally specific data and reassurance about the safety of in-person education provided by 321 screening programs. Without this full assessment, the interpretation of cost/case detected is difficult. English-language learners, and economically disadvantaged students than the state-wide average. While 337 the costs of assays will likely be similar in most settings, resources needed for implementation may 338 differ widely, for example, the availability of parent volunteers and the time needed for outreach, 339 education, and obtaining consent for all participating students. The Massachusetts state-supported 340 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ; is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ; 0 (0%) 0 (0%) 0 (0%) 0 (0%) 1 (100%) 0 (0%) 3 (15%) 0 (0%) 2 (10%) 3 (15%) 6 (30%) 6 (30%) 0 (0%) 0 (0%) 0 (0%) 2 (25%) 3 (38%) 3 (38%) 3 (23%) 0 (0%) 2 (15%) 1 (8%) 4 (31%) 3 (23%) 3 (25%) 0 (0%) 1 (8%) 1 (8%) 5 (42%) 2 (17%) 0 (0%) 0 (0%) 1 (11%) 2 (22%) 2 (22%) 4 (44%) number offered testing, number tested, number of those who tested positive, and the positivity rate 370 (%). The positivity rate ranged from 0.0%-0.13% for educators and staff and 0.0%-0.21% for students. 371 372 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. costs. Pooled and individual refer to the type of test; state-supported or non-state-supported refers to 378 the source of funding for the screening programs. Across all the groups, assay type accounted for more 379 of the costs, though with a greater proportion in the individual testing and for non-state-supported 380 screening programs. 381 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 13, 2021. ; https://doi.org/10.1101/2021.12.10.21267568 doi: medRxiv preprint

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For districts that did not report the cost of assays, we estimated those costs based on the vendor used

Estimated personnel costs were calculated from mean number of hours * average publicly reported salary for each type of employee, weighted across types of employee 359 reported. Numbers of personnel and hours were reported in strata; we assumed an inclusive upper bound for each stratum. For ranges where an upper bound was not explicitly 360 specified (>25 and >50)

Sensitivity analyses: lower and upper bound of mean cost estimate, using lower and upper bounds of strata of number of personnel and personnel-hours spent

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