Understanding the Value and Feasibility of Routine COVID-19 Testing in Schools

[SARAH HANCK]

We need to take lots of mitigation measures to prevent infection, particularly in schools. We do need to wear masks. We do need to think about how to distance properly. We do need to think about ventilation, et cetera. But the real missing piece was testing.

[J.B. WOGAN]

I'm J.B. Wogan from Mathematica, and welcome to On the Evidence, a show that examines what we know about the today's most urgent challenges and how we can make progress in addressing them.

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Okay, on this episode of On the Evidence, we're going to talk about the use of rapid Covid-19 antigen tests as a routine screening tool in K-through-12 education. A report from Mathematica and the Rockefeller Foundation in early February drew lessons from six pilot sites that agreed to implement antigen testing in schools. Those sites, by the way, were Central Falls, Rhode Island; Los Angeles; Louisville; New Orleans; Tulsa, Oklahoma; and Washington, D.C.

The Mathematica report found that weekly testing of all students, teachers, and staff could reduce in-school infections by an estimated 50 percent. Maybe just as important, regular testing appears to make students, parents, teachers, and staff more comfortable with resuming in-person learning. But the report also found that implementing an effective testing program would not be easy. Schools would need substantial support and coordination from national, state, and local education and public health authorities.

On this episode, I speak with Jennifer Harper, Sarah Hanck, and Divya Vohra. Jennifer is the project manager in Tulsa for Covid antigen testing in schools. Sarah is a senior advisor at the Rockefeller Foundation for Strategy and Impact. And Divya is a senior researcher at Mathematica who co-authored the report about lesson from the sick pilot site.

Because things are evolving so fast around the pandemic and reopening schools, I need to timestamp this interview. We spoke on the afternoon of March 18th. Earlier that week, the U. S. Department of Health and Human Services announced that it would provide $10 billion to support the use of routine Covid-19 tests in schools. The day after our interview, on March 19th, the Centers for Disease Control and Prevention announced that it was changing its guidance around what was considered to be a safe physical distance, from six feet to three feet, for students to be in classrooms in most settings. Both developments are expected to help more schools resume in-person instruction.

Jennifer, Sarah, and Divya discuss the research findings, the impacts of the research so far, more recent lessons based on Tulsa's experience implementing testing, and what leaders in schools and communities across the country need to know about using antigen testing as a screening tool. I hope you find this conversation useful.

All right, so we'll be talking about Covid-19 testing in schools and, specifically, lessons learned from research published in early February by Mathematica on the use of regular screening tests for Covid-19 in K-through-12 schools in six pilot sites. Before we get into the finding, can we talk specifically about the kind of testing being used in these pilot sites? Divya, I thought maybe you could start us off here. What is a rapid antigen test and how does it compare to other types of testing or surveillance?

[DIVYA VOHRA]

Sure. So, antigen tests are one of two types of tests that can be used to detect a current infection for the Coronavirus that causes Covid-19. So, antigen tests detect a specific protein on the Coronavirus, and only molecular or PCR tests, which detect the virus's genetic material, antigen tests can be administered and read at point of care, which means that you can administer the test and then also read the test result in the setting where you actually do the test for the person. Molecular tests, on the other hand, you typically have to send the sample or the specimen that you collect to a lab for processing.

So, people like antigen tests because, comparing with molecular tests, they're relatively cheap, relatively easy to administer, and they typically produce results more quickly than molecular tests. The downside is that they're known to be slightly less accurate than PCR tests or molecular tests, so you could end up with more false negatives or false positives if you use antigen tests.

[J.B. WOGAN]

Okay, perfect. And in the report, I think they refer to these as screening tests. Are antigen tests the only kind of screening tests out there, or is it one of a variety of options for screening?

[DIVYA VOHRA]

So, it might be helpful to distinguish here, there are two categories of, like, types of tests, there are the antigen tests that we work on this project and the molecular tests I just talked about. But any test could be used for a variety of different purposes. So, there are a few different ways that antigen tests are being used. One is clinical diagnostic testing, which means testing for people who have symptoms or possibly a history of close contact with an infected individual, so that's to diagnose Covid-19 infection in somebody in who we have a reason to believe they might already have it.

And then there is screening testing, which is routine testing of individuals who don't necessarily show any symptoms or don't necessarily have any known exposure, in an effort to identify infected people sooner and reduce the risk of transmission. And then there are surveillance testing, which is used to measure population problems to the level of infection in a community, and that's where you would test everybody, or a sample of everybody in a population on a regular basis to get a sense of how much infection there in that population.

So, antigen tests, like the BinaxNOW test that were used in the study, can be used for any of those purposes. The pilot sites that we worked with were mostly opting to do some form of screening and/or surveillance with their BinaxNOW antigen tests, which is in line with the learning goals of this demonstration project. But they can also be used for diagnostic testing in some settings.

[J.B. WOGAN]

Okay, perfect. Okay, so Sarah, why was the Rockefeller Foundation interested in gathering evidence on the use of rapid antigen testing in schools?

[SARAH HANCK]

Yeah, I think last year was a real really -- we really had a big push in testing writ large. We started earlier in the year issuing a national plan that called for more testing, a lot more testing than we were currently doing. And we quickly honed in on the feeling that screening testing was a gap. That's something that we weren't doing enough of and we needed to do much more of. And so we built on that plan by investing in some academic partners, Duke Margolis and Johns Hopkins University to develop protocols to help understand when one should use which type of test for what purpose and how frequently, and then we quickly set up some pilots to see if those protocols worked and how they may need to be refined or improved, and that's where we started working with sites like Tulsa, Rhode Island, L.A., D.C., New Orleans, Louisville, and quickly realized you can't have pilots without tests, so we stood up a partnership with HHS, with the Department of Health and Human Services, to release more than 140,000 BinaxNOW antigen tests to these pilot sites. And then we quickly brought on Mathematica to help us understand and learn as we go what's working what's not, what's feasible, what helps to make this kind of protocol effective or acceptable. Yeah, the report was really the culmination of those early lessons and recommendations.

[J.B. WOGAN]

Okay. And so, is it fair to say that, from the Rockefeller Foundations perspective, antigen testing, regular screening testing in schools is going to be an essential component to us reopening schools and getting back to some sense of normalcy in K-through-12 education; is that right?

[SARAH HANCK]

Absolutely. We really felt like we need to take a lots of mitigation measures to prevent infection, particularly in schools. We do need to wear masks. We do need to think about how to distance properly. We do need to think about ventilation, et cetera. But the real missing piece was testing. The one that was really complicated, the one that we just hadn't figured out how to do in a school setting, and so we felt like we needed to put resourcing and technical assistance behind that problem to really unlock what it would take to do it effectively.

[J.B. WOGAN]

Okay, perfect, and hopefully we'll talk a little bit more about the interdependence of those different mitigation measures, the testing, in addition to other things like social distances, masking. But, Jennifer, I want to turn to you, from the perspective of Tulsa, what was appealing about participating as a pilot for this antigen testing in schools? What was the motivation or what was the selling point for you all?

[JENNIFER HARPER]

Well, I would have to say that that's layered. There were many selling points to a project like this for us, including the most obvious, is helping our kids and our school buildings feel safe. Probably the highest motivation is in two categories; getting kids back into schools so we can have them with the learning objectives that they had signed up for previously and help them transition during a period of a world of uncertainty and chaos that has created things like higher DV rates, domestic violence, things that they're dealing with at home. Being able to get the kids back in the school buildings and putting resources around them is a major factor for Tulsa, thinking about things from, like, a trauma-informed perspective.

Also, giving the ability back to our parents and the adults in those families able to go back to work. We heard a lot from different parents that they were struggling because they were trying to juggle having kids at home, doing online learning, but, yet, they needed to go into the office and work and different things, and it created almost unbearable stress. So that was a major motivation. But we were also very honored to have that privilege of partnering with the Rockefeller Foundation on these national efforts, not only because Rockefeller has done such a fantastic job of really looking into the details and the pieces of this that were something that we didn't have the time to do, and create things like national recommendations that we could use and give us a starting point to start thinking about, well, how do we take this and mold it into our community's needs. And that was really, really beneficial from a decision-making perspective, but also from the partnership with the public Health Department, and the reality of how we're moving things forward within, well, now vaccination efforts. But at the time, you know, with those mitigation efforts that were mentioned earlier, social distancing, et cetera.

[J.B. WOGAN]

And could you remind me real quick, Jennifer, what is the status of antigen testing in Tulsa.

[JENNIFER HARPER]

It is being done currently. So, back in December, we did a pilot testing, and we started with voluntary staff and teacher, because the kids were still doing online distance learning. Then the kids were able to come back in, like, a tiered system. February 23rd, tier three and four students, the special needs, and grade four through seven, and junior high and ninth graders all returned into the school buildings. And then it kind of went from there into a tiered fashion, to where, now, all of our students are back into the school building. So we were able to actually launch the student testing part of this last Thursday. We're very early in the results of what that is.

But just to give you a little bit of a snippet of what we looked at with the staff, we have now already been able to test over 30 percent of teachers and staff, administration, everything in the schools, just from the pilot testing to the state, and that's showing us that we had about a 1,255. That makes up about 30 percent of the total. 1,184 were negative tests, but we did have 23 positive tests. We had 48 invalid tests as well, and so we wanted to make sure that we were watching that as we got rolled out with all of our students in different pieces, because that does kind of tell you a little bit, especially the invalid testing. Also, opt ins is the strategy that we're using. It's an opt-in form. So we have, to date, about 424 students that have opted in, and that would have been from last Thursday to today.

[J.B. WOGAN]

Okay, just to timestamp that, you're saying last Thursday. We're talking on Thursday, March 18th, and this podcast will probably go out -- I believe it's going to go out on Wednesday, the 31st, so the numbers will be slightly higher by the time the podcast comes out, but, still, those are relatively recent numbers that you're sharing with us today.

So, Divya, do you want to talk about some of the main findings from the report that came out in early February? What would you say that are two or three big takeaways from this research so far?

[DIVYA VOHRA]

Sure. Well, I think one of the big takeaways related to everything Jennifer was just saying is that, across all the pilot states, we were hearing a lot of enthusiasm for testing. In all pilot sites, I think students and families, teachers and staff were all very, very supportive of testing as a way to get folks back in the classroom. They said that testing made them feel safe. It made them feel cared for. It made everybody feel more comfortable with in-person learning. So just a lot of enthusiasm for schools who are considering implementing some kind of testing program.

At the same time, we know that testing is really challenging to implement. It takes considerable resources, and the logistical and regulatory considerations that schools had to navigate were very complex. So schools really needed coordinated support and guidance to navigate all of that and set up their testing programs.

We also learned from our statistical modeling that testing can be a really effective way to reduce in-school transmission above and beyond other mitigation measures that schools are taking, like masking and distancing. So, we learned, for example, that in high schools, testing all students, teachers and staff on a weekly basis could reduce in-school infections by about 50 percent.

[J.B. WOGAN]

Okay, perfect. And Jennifer and Sarah, are there any other findings from the report that you'd want to call out? Any other major takeaways?

[JENNIFER HARPER]

Well, I'll jump in too and just say that one of interesting pieces here that we're learned, especially it's a little newer -- I don't remember if we have it highlighted within the report, but something of note, especially in high schools -- it's mainly the transmission because of what they bring into the school building not what's within the school building itself that is the challenge, and so that partnership from a public health perspective of what that transmission rate looks like in the outer community is important, and actually is a factor in the testing strategy that we choose. And we chose, at least at the very beginning, especially those pilot sites, three Zip Code areas that had high transmission rates from a community-wide perspective, and that helped reduce the amount -- potential amount of transmission from the community into the school buildings, and so that's a big piece to it.

[J.B. WOGAN]

Okay. All right, so this question, we've kind of already anticipated it a little bit, but I think it's an important point so I do want to touch on if a school implements antigen testing, does that mean things could go -- otherwise go back to normal. I guess this is my way of asking what other safety measures need to be in place in strategies to reduce disease spread? Divya, or Sarah, do you want to take that.

[DIVYA VOHRA]

I'm happy to start us off, but would love to hear what Sarah thinks too. So, the modeling result in our really focusing on the added benefit of screening testing above and beyond other mitigation measures like masking and distancing. And we know that those other measures are quite effective at reducing the risk of transmission, and, in fact, CDC guidelines recommended that schools implement those kinds of measures. So, we've heard some people refer to this as, like, a Swiss cheese strategy, so one mitigation measure is perfect; right? They all have some holes. But when you layer them on top of each other, you lower the risk of the virus making it through all of the holes. So we think of testing, really, as one layer in that kind of Swiss cheese strategy, or to mix my metaphors, it's a tool in the tool kit. But, really, we want to make full use of all of the tools that we have available to us. So testing should be complementing those other strategies but it's not a replacement for them.

[SARAH HANCK]

Yeah, I completely agree with what Divya just said. One thing we are seeing moving right now is that the CDC may be coming out with revised guidelines tomorrow, we believe, on the distancing requirement within school, so that there's new evidence coming out of Massachusetts, and elsewhere, that we know longer need to rely on a six-foot distancing rule, which really limits the number of teachers and staff you can have in a school building at one time, that we may be safe enough for a three-distance rule. So I think we're all encouraged that that might help get more kids and staff and teachers back in school sooner.

[J.B. WOGAN]

Okay. All right. And as a reminder that I think the evidence is evolving and what we're learning about this virus is changing a little bit by the month, if not the week. Jennifer, the report mentions that parents in some of the sites were not comfortable with twice-weekly testing but were okay with once-weekly testing. I think this is true at multiple sites. What concerns were you hearing from parents about testing? In spite of that kind of enthusiasm you mentioned earlier, what were the concerns you had to address as well?

[JENNIFER HARPER]

Yeah, it's important to remember the context of what the conversation was at the time that that surfaced, because that was late last year too. And so community-wide discussions circled around a little bit of different things than it does right now, where the vaccinations are in play and all of those other pieces. But, at the time, you know, the kids' safety was obviously number one, and that's been a consistent, but how that looks was evolving. And thinking through the privacy of the student, and the inherent almost invasive nature of how the test works was a concern for some of the parents in the fact that, you know, it's new. It was a very new topic at the time. They didn't quite understand it. And most of the parents had not done that testing themselves yet, and so it felt like a large leap to say, well, we're going to do it multiple times a week and, potentially, have to take the kid out of a classroom setting in order to do that. That felt like we were asking more from them than what they were comfortable with at the time.

Now, you know, having something in place like that, and most people have kind of gone through the testing process and are a lot more familiar with some of that, it could be a completely different conversation. That's the, I guess, beauty, and/or challenge of my job working on the ground, is that, from an implementation level, things can change daily, and I know that's all the way up through the national level. But when you're looking at a strategy, and a testing strategy is, like, key to everything, I feel like Tulsa is probably a very relatable model for a lot of other schools in the nation, because we weren't exactly -- we were very much human-centered and action focused.

It wasn't that we had certain levels of, like, data infrastructure in place in order to do massive surveying and polling and different things that, you know, we would love to do, but we hadn't had this type of event ever happen before from a public health standpoint, and so there was a lot of team effort. I'm so that thankful TPS was willing to step up -- and they have some incredible administrators there -- to stand in the gap of where some of those infrastructure pieces, maybe a policy that worked against us that we didn't know was there, that type of stuff, to work through those things in order to actually implement a strategy that would work for the community at large. And so it's a process, I would say.

[J.B. WOGAN]

Okay. You said TPS, is that Tulsa Public Schools? Okay, I just wanted to make sure we're crediting the right organization. All right. And in terms of the invasiveness, Divya, you may have said this earlier and I just missed it, but is that a nasal swab?

[DIVYA VOHRA]

Yeah, the BinaxNOW tests are a nasal swab, but they're not the kind that goes sort of all the way up your nose and people were referring to it as, like, tickling your brain. That's not the BinaxNOW. It's still a Q-tip up your nose.

[J.B. WOGAN]

Okay. All right, that's helpful clarification. All right, so, Jennifer, I have another question for you. The report recommends, yes, follow the evidence-based guidelines for testing, but also tailor the testing strategy based on community needs and available resources. How did Tulsa account for the local community preferences and resource constraints in developing the testing strategy?

[JENNIFER HARPER]

Well, feel free to cut me off at any point, because this could be something I could talk about all day, and it's the pivotal piece of my position and other positions are doing. It's, again, layered. But I would say, referring back to what I said earlier of how appreciative we were of Rockefeller and the resources that they pulled together, you know, one of those resources was a cross-city learning group, CCLG, that you could learn from other pilot cities that are doing it, and that was incredibly beneficial to us, because thinking through here's a template or a framework from a national model, evidence-based practice, we want you to be able to do these things. This is what we're wanting to see come out of it, and look at our community and see where the gaps are, whether it's like the data infrastructure on the back end.

Also, accounting for the fact that the BinaxNOW testing units were not designed to be able to aggregate data on the back end. They are like very much individual type testing units, which was a challenge when you've got a large school district at 77 sites across a metropolitan area and didn't have, like, a centralized framework that would be able to allow for quick state reporting. So, that's one of the many pieces, because the report and the frameworks that we would get from Rockefeller and all of those places help us to think about, okay, we may not be able to hit this level of information that we want to get to, but now we can start figuring out what framework can we put into place to get there, and what needs to be done in order to get us to a point where we're not only doing this from almost an old saying is ambulance chasing; right? There's a fire, we're trying to put it out, and we're just trying to keep this moving forward, but not doing it just in that aspect, but from, like, a long-term mentality of seeing, okay, we hadn't had this type of situation ever happen before but we have now, so we need to take this opportunity to leverage what we can do to mitigate what our issues would be in the future. And, again, I keep going back to the data framework, because that's a big part for Tulsa.

Another piece of that, again, that Rockefeller was incredible to help us with, was connecting us with a group called Project Beacon. They work out of Massachusetts, and they are doing a statewide thing now, actually, that helps with reporting, and it's basically a data framework. And it has communication applications with the parents, so you know whether you got positive or negative. It has a lot of different things in it that we needed and wanted to be able to partner with them to do. So, Rockefeller, they stood in the gap and helped us to have that conversation, work through the needs, help us think through, in our testing strategy, from an evidence-based perspective, what do we need to have in place to make sure that we can report out the pieces that is really going to be helpful for us from a long-term perspective, not just meeting reporting requirement from a state level but also thinking through, again, long term.

We are in contract with them, actually right now, and they are developing that platform for us as we speak, and that's a huge win for us to be able to have that not just for this area but for future. So I'm trying to paint the picture from taking that evidence-based framework, looking at it from, like, a local implementation level, and then how do you fill the gaps. And a lot of times it's very practical and simple and so necessary, and sometimes not available to you is just is there someone who can do this and how do we get them into that gap in a way that's going to be effective. And that's just a really good success story that we've seen from our perspective.

[J.B. WOGAN]

Okay. And I'll put this question to the group. In the report, trust comes up about a dozen times, in the context of trust of leaders, trust of sources, trust of messengers. Based on your experience, why is it important to focus on building trust when implementing a testing plan in school?

[JENNIFER HARPER]

Oh, it's vital. Sorry to jump in there, but I'm sure you guys agree with me, which is why it's in the report, and I'm glad that they highlighted that. Trust is key to everything, especially when, from our perspective, what we had to be is very human centric and a little less relying on certain infrastructure pieces or certain things, because this was new to our district, and we were having to figure out what does magnitude of this type of testing look like on the ground. You end up having to create a team in the effort. So, I was brought in because I'm a part of a collaborative effort that got us to the point of being a pilot city. That includes the health development, the public schools and the city. And that's just from that angle.

When you start going into the public schools, you know, you've got several different departments who were over different things, and I can't stress this enough, they have stepped up to the plate time and time and time again to go above and beyond to make this happen, because they believe it will be good for the kids. And if they believe that, they're willing to step up. And we have people from the data team. We have people from operations, the nursing staff, the nursing director. We're using our own nursing staff within the school to do the testing, and so that is a major part of our strategy as well. We were able to get that piece to hear from the community that they just didn't feel as comfortable with it, thinking about it from a third-party vendor coming in. But they know their nursing staff. A lot times the kids have been in the nurse's office and all of that, and so there was a little bit of a trust factor there going that direction instead of going to a third-party vendor.

So, yeah, I can't stress this enough, if you don't prioritize that trust, not just trying to get it for one thing but for a long term, like relationship, as this project obviously continuously evolves and changes at every turn, it's been a very challenging project. I'm not going to lie, because it is, it's changing at all times. And when you're on the ground doing logistics, it's not easy. But you have to be very focused on that, because people remember, and we're in an uncertain climate, and once you lose trust, it's very difficult to get that back. So, I would say it's probably one of the key things to our implementation here.

[J.B. WOGAN]

Okay, excellent. Divya or Sarah, do you have anything you want to add on the topic of trust?

[SARAH HANCK]

I'm happy to add. I think trust is critical, and I don't know who originally said this, but I quote it often, that progress only moves at the speed of trust, and that was very much in play here throughout these pilots and this work. I think we learned. We brought in Mathematica because they are a trusted partner that's done this kind of work before; that we had worked with closely before; that we knew were up to the task of very quickly gathering evidence and gathering data and evidence that others would trust and find reliable and could trust to incite action, to compel others to act.

And I think we learned that trust was essential to build as a community across these pilot sites, the CCLG, the network, learning collaborative setting, because this was something that no one had ever done before, and we were learning, all of us, as we went, and so we really needed to establish that trust across sites to learn quickly, establish that trust with these external partners, with Duke Margolis, Johns Hopkins, Arizona State University, Mathematica, to quickly build trust across sectors, across partners, to solve the problem and bring everyone's expertise into the mix. And I think we learned that without quickly building trust and relying on trusting each other, that we had kids' best interest and schools' best interest in mind throughout the entire process, which wouldn't have happened.

[J.B. WOGAN]

You mentioned inciting action, and I think that's a nice segue for the next question, which is, what has happened since this report came out? How have the findings influenced the conversation and led to action in the Covid response? Sarah, do you want to take that up?

[SARAH HANCK]

Happy to. Yeah, I think we have been really pleasantly surprised by the speed at which this work has informed action at the national and state and local level. I think each of the pilot sites have their own stories to tell about how these pilots informed their sites', their cities', their states' actions, and we've been really excited to see that the collective learnings across these sites and the synthesis of those learnings in this report, we were able to share back with the Department of Health and Human Services, and it has very quickly been able to paint a very detailed and useful practical picture about what recommendations the federal government can take, what steps they can take to really alleviate some of the pain points and logjams that were preventing screening testing from really taking off.

And just yesterday, on the 17th of March, HHS released a $10 billion investment, particularly in screening testing to ramp that up nationwide, and so that funding will go directly to states in April to make this possible, and not just resourcing for tests themselves but resourcing for the technical assistance that's needed to stand this up, resourcing to break down some of the regulatory hurdles that these very pilots have surfaced. And so I think that our ability to collate and capture and share out what the struggles that these sites have had with standing this up pretty much, you know, on their own as pioneers, our ability to do that has really directly affected the resourcing and policy decisions at the national government level.

[J.B. WOGAN]

Okay, so that is really big impact in a short timeframe. I know that's not common for policy research. What were the ingredients or what do you think were the major factors that allowed for such quick action to take place after this report came out?

[SARAH HANCK]

Reflecting back on our conversation about trust, one of the things that was just a very practical way that I think these findings have influenced action is with the Biden transition and the transition from the Trump administration to the Biden administration, there was a new cast of leaders and policymakers, and this was very well timed to be able to deliver immediately upon starting a new role, here is what we're learning, here is what's hard, here is what needs to happen, here are the recommendations you can act on right away. And so our ability to have frank conversations directly with the national testing coordinator, that all of the CCLG members were able to directly voice their pain point and their concerns, which provided a lot of color to the report that Mathematica developed, and the findings, that kind of conversation was able to really propel action very quickly for an administration that had set opening the majority of K-12 schools, or K-8 schools, I guess, in the first 100 days. It's really allowed that mix of data and action. It was really well timed for the administration to really act quickly to achieve that goal.

[J.B. WOGAN]

Divya, is there something you wanted to add? If you don't mind, two things that I wanted to add. I wanted to first go back to the question about sort of how to take this work forward and thinking about how this work is useful and actionable. But I wanted to add that something that we've been thinking about, that our team has been thinking about is, how to continue to update some of our modeling work specifically to help inform decision-making for other schools or districts that are thinking about implementing testing, or trying to figure out how to implement screening testing.

[DIVYA VOHRA]

So, I'll share that we're working right now on an interactive tool that's sort of an interactive version of our model that would allow you to see the potential value of a particular testing strategy in your school, based on specific inputs, like the underlying the community infection rate, the type of school you're considering and all that kind of stuff. So we're excited to put that out in the world. And I will just say generally that I think it's always gratifying and exciting for us, as public health and public policy researchers, to be able to contribute to conversations like this, and it's really meaningful for all of us to be a part of such an interesting and diverse group of actors here, group of partners who have all been working so hard to learn about how we can make testing possible in schools.

[J.B. WOGAN]

And that tool will be free and publicly available? Anybody can find it online?

[DIVYA VOHRA]

Yes, that's right. It will be a free website that anybody can access, and we're planning on putting that out within the next couple of weeks.

[J.B. WOGAN]

Okay. We can take or leave this, but I did notice there was an interesting detail in the report about the concerns around false positives and equity considerations that need to go into that, so I was going to ask, what equity considerations should be top of mind for school community leaders interested in implementing rapid and regular Covid-19 screening tests in schools? And I'm thinking specifically of concerns rates in the report, about the impact of false positive, the impact on families and working families?

[DIVYA VOHRA]

So, I will say I think this is something that we heard across the board from all of the pilot sites that they're really thinking about this. I mean, of course, any positive test result has implications for the person who tests positive and the people that they live with and have close contact with; right? So, if a child tests positive and they need to isolate, they need to stay home from school, well, you know, then somebody needs to arrange for childcare. That might mean missed work for their parent or their caretaker, and the sort of the ripple effects can be really significant.

From what we heard -- and this is consistent with what Jennifer was saying -- you know, all of the people involved here are concerned about the safety and the well-being of the students and the teachers and staff who work in the classrooms; right? So, to some extent, I think there is a recognition that, like, when a positive test happens because a person is truly infected, then it's important to take all of those steps.

But the false positive is, I think, something people really worry about. If they're going to go to all these lengths to isolate and self-quarantine and it turns out they didn't have to do that, that's a big sacrifice to have made. So, I know a lot of the sites have been talking about how they kind of manage that, and to what extent they can provide support to students or teachers or staff who test positive, whether that's connecting them with follow-up molecular PCR testing or whether that's connecting them with telehealth appointments if they're sick and need support. It sounds to us like many different schools are thinking about different ways to kind of deal with the ramifications of a positive test.

We do think that the sort of regular antigen testing that these schools are working on and trying to implement, that, yes, there is some risk of false positives, but if you put that next to the potential benefit of identifying asymptomatic cases who might otherwise go undetected, there is a tradeoff here; right? The benefit of identifying and isolating those asymptomatic cases might really be worth that risk of, potentially, more false positives.

[J.B. WOGAN]

Okay. Perfect. And, Jennifer, anything you want to add about the Tulsa experience or perspective?

[JENNIFER HARPER]

Well, we are still very early in testing students, so at this stage in the game, we haven't had an actual case that was a false positive. But we have had conversations, just like Divya was explaining, about the potential for using PCR testing for confirmatory, and when we get to the level where we need to do that, how do we facilitate that in a way that's, again, from our perspective, thinking about it from a trauma-informed perspective, which also has an equity lens, how do we provide that in a way that's not difficult or there's any access issues.

So, a lot of our population is spread out over a metropolitan area and transportation is a very real need, and we have had times where our buses, we have a bus driver who is out, because they are sick with Covid and they can't run, and then the students are struggling with transportation, so we have a company here that we're talking to about being willing and able to provide that transportation to view those confirmatory tests if needed. So we're early in the discussion, but nothing has been set yet. Again, we haven't had a false positive yet, so we're very thankful for that.

[SARAH HANCK]

I'd just love to add that, in a broader equity perspective, we, as a foundation, were really concerned to see screening testing being ramped up really quickly and rapidly at private universities and at private independent schools, but there was a real gap in reaching down into the public-school setting, particularly last fall. And we were able -- that assumption was validated by a national scan that we worked with brands to do to profile who are these early adopters? Who is taking up testing in a school setting? And they also concluded that it's something that high resourced schools were able to take up, because of its complexity and its cost and its challenges, but it was really not trickling down do the public-school setting, and particularly low-resource districts and low-resource schools, and so we're really hopeful with the new push this year and the resourcing and the technical assistance that's being stood up for schools, that that may change this year.

[JENNIFER HARPER]

I'll jump on that too, because, again, public schools in Tulsa, and it's a very real need to have resources. Again, we were very thankful for a lot of the resources that we were put in touch with through Rockefeller and some of our partnerships within the CCLG group. But a lot of our pieces of things that we've had to work through were just us having to sit around a table with our team and hash it out and learn how this is going to effectively be implemented here within the State of Oklahoma, because we have our own state reporting requirements, like a 24-hour turnaround and other things that may not be applicable in other states.

But just from the perspective of being action oriented and almost from like an agile project management perspective, where you're running sprints the whole time, that is where Tulsa has been, and we wanted to be able to show, like, other school districts that are public school districts are in the same level of where we are; that it can be done, and that there is a way forward, and that it doesn't have to be fully resourced in order to do this type of testing, and we're an example of that.

[J.B. WOGAN]

Okay. So, I'll put this question to the group. Is there any data or other kinds of evidence that you wish we had informed for strategies, or it just isn't there yet? And I would include in here data that is forthcoming, maybe in the Mathematica research, but just hasn't become available yet?

[SARAH HANCK]

Yeah, I think the Mathematica report really solidly helped us answer the question of whether our screening testing is acceptable to students and families and teachers. And the answer is, yes. And it really also helped us definitively answer the question, is it feasible? The answer is, yes, with a lot of help. And I think the remaining question that we need to just tease out more is, how effective is it preventing in-school transmission of infection, and how effective is it at really keeping schools open and maximizing in-person learning? If we're able to keep infection rates low, are we able to keep schools open longer and have more kids back in the classroom? And I think we just need more real-world evidence, and we need time to really generate and gather and understand that real-world evidence to supplement the really powerful modeling that Mathematica was able to do.

[J.B. WOGAN]

Thanks again to my guests, Jennifer Harper, Sarah Hanck, and Divya Vohra. In the show notes, I'll list links to the research we discussed on this episode. You can also find those resources on the Mathematica blog that accompanies this episode. As always, thank you for listening to another episode of On the Evidence, the Mathematica podcast.

There are a few ways you can keep up with future episodes. Subscribe wherever you find podcasts, or follow us at Twitter. I'm @JBWogan. Mathematica is @Mathematicanow.