Here’s why Utah’s COVID-19 testing in schools went from national model to abandoned failure

Here’s why Utah’s COVID-19 testing in schools went from national model to abandoned failure

Edited by Derek Kravitz

As Utah ran out of COVID-19 tests in January and many districts briefly moved to teaching online, lawmakers suspended the state’s “Test to Stay” program — a strategy once praised nationally as an ingenious solution for halting outbreaks in schools.

By testing all children any time that 1% of a student body was diagnosed with COVID-19, schools had enabled thousands of uninfected Utah kids to keep attending in person without spreading the virus in classrooms.

Test to Stay failed in the onslaught of the coronavirus’s highly contagious omicron variant. But the reason wasn’t just that omicron overwhelmed the state’s test supply.

Utah legislators have systematically gutted Test to Stay, experts say, chipping away at its effectiveness at multiple points until it had little hope of catching outbreaks before the virus spread between students, according to data and records obtained by The Salt Lake Tribune and the nonprofit news organization Documenting COVID-19.

This report is based on hundreds of internal emails, testing data and dozens of interviews as part of a collaboration between The Salt Lake Tribune and the Documenting COVID-19 project, which is supported by Columbia’s Brown Institute for Media Innovation and MuckRock. [Read supporting documents here.]

When schools opened last fall with a drastically relaxed version of Test to Stay and a ban on mask requirements, COVID-19 cases among Utah children exploded — well before omicron began circulating. The new Test to Stay was not keeping up with cases like it had in the spring.

And when schools reopened after winter break with omicron spreading, they quickly tallied enough cases to trigger the weaker version of Test to Stay — “which frankly, is already too late,” said Dr. Michelle Hofmann, deputy director of the state health department, at a January news conference.

“We know that it’s already gone through the full school at that point.”

Republican Sen. Todd Weiler said he expects Test to Stay to be revived at some point — but it will be the less-strict version created by his 2021 bill. And under new legislation sponsored by Weiler and signed into law by Gov. Spencer Cox in February, Test to Stay will return only when Cox, legislative leaders, the state health department and the superintendent of public instruction jointly decide it would be effective to use.

It will also be used without other mitigation layers that health officials say worked as a layered sieve, slowing the virus’ spread before people knew they are infected.

Pioneering success inspired testing programs in other states

Utah’s initial version of Test To Stay, launched in November 2020 amid ballooning new cases and hospitalizations, was vaunted as “a simple solution” to school closures: Any time 1% of a school’s student body was diagnosed with COVID-19, all students would be tested in order to keep attending classes in person. Those who tested positive or those who refused to test would have to stay home.

In its first few months, the rule played out exactly as health experts had hoped. Not only were schools staying open when they’d otherwise close, they were staying open without spreading the virus. When schools were required to test, the vast majority of results were negative. Typically only about 1% of the students who tested came up positive, said Dr. Adam Hersh, a professor of pediatric infectious diseases specializing in epidemiology at University of Utah Health.

This low test positivity rate suggested Test to Stay was catching cases before students had the chance to infect each other in their classrooms, said Hersh.

The results from Utah’s first few months of Test to Stay were published by the Centers for Disease Control and Prevention and held up as a model for other states and school districts to follow. Even as others jumped on board, Utah’s system remained the shining example: while school districts in other states struggled to figure out testing logistics, the Utah public health department provided local schools with all the information they needed to run this program.

“Utah has been one of the leaders from the beginning of the pandemic in terms of school testing,” said Mara Aspinall, a professor of biomedical diagnostics at Arizona State University. Aspinall recalled that Utah was one of the first states to pilot a testing program and has been “aggressive” in pursuing this strategy.

For example, schools in many other states had to coordinate their own test events and manually process the results on their own, despite having no experience or staff to handle medical records or manage a health service at that scale. By contrast, Utah built a customizable data-entry system for school testing. That meant school administrators and parents could easily access test results, which also were automatically uploaded to the same databases health officials have been using to track all coronavirus test results.

After pioneering this high-performance Test to Stay system, the state made changes to how schools would be allowed to handle COVID outbreaks. And it functioned very differently when schools reopened in the fall.

Test to Stay was faltering long before omicron hit

As the delta variant spread around Utah in late August and early September, testing sites were overwhelmed, with patients relieving themselves in bushes while waiting in hours-long lines. UDOH had shifted many of its free, public testing sites to a private contractor to free up state and National Guard staff to work at testing events in schools.

But districts didn’t take the state up on voluntary testing events, and so many kids were testing positive at community sites that schools and health departments couldn’t keep up with contact tracing or confirm that infected kids had been in the classroom. That meant cases weren’t being counted as “school-associated” cases, which is how a school tallies enough cases to trigger Test to Stay. Data disparities showed official school tallies were far behind the actual number of known cases.

At this time, real-time data showed cases among elementary-aged children were higher than they’d been at any time during the pandemic, even with most Utahns fully vaccinated. Hospitalizations spiked accordingly, contributing to delays in needed care for children suffering from chronic illness.

Where school-wide testing in the previous school year identified cases in about 1% of students, positivity rates in the fall semester typically were closer to 5% — and sometimes much higher. After Edgemont Elementary in Provo triggered Test to Stay in October, the school-wide testing showed more than 8% of the students had contracted the virus. At Oakcrest Elementary in West Jordan, only about half of the students agreed to get tested when the school triggered Test to Stay in November — but nearly 12% of them tested positive.

At Oakcrest, it appears the damage already was done. Between the students whose positive tests triggered Test to Stay and those who tested positive in the subsequent schoolwide “test event,” more than 10% of the student body was found to have COVID-19. Rather than quickly isolating a small number of positive cases among students before the virus spread to other kids, Test to Stay didn’t slow transmission like it used to.

And contact tracing suggested transmission was happening at school. In early 2021, Test to Stay results generally showed “sporadic” cases that didn’t appear to be linked to each other, or to the previously-known cases.

“What we observed this fall was that when school-wide testing occurred, we found what seemed to be more clusters,” Hersh said.

Oakcrest Elementary wasn’t alone, according to state data obtained by The Tribune and the Documenting COVID-19 project. Three other elementary schools that triggered Test to Stay in October and November found infections in more than 10% of students.

A year earlier, 15 cases were enough for a school to shut down. And during the introductory version of Test to Stay, only one school’s positivity rate from a Test to Stay event surpassed 2%.

Health experts point to a number of changes that undermined Test to Stay in Utah’s schools, even before the omicron variant obliterated the state’s supply of tests.

Utah lawmakers required more cases to trigger school testing, against health officials’ advice

When the legislature a year ago passed the law codifying Test to Stay, it doubled the rate of known infections that triggered Test to Stay. Before March 2021, schools had to test all students if 1% of all students had been diagnosed with the coronavirus within two weeks, at least at schools with more than 1,500 students. Schools with fewer than 1,500 students had to conduct testing if 15 students had already tested positive.

Legislators, however, voted that schools couldn’t require testing until 2% of students had already tested positive, or 30 students in schools with fewer than 1,500 kids.

That longer waiting period gave the virus a lot more opportunity to spread before students had to test negative to attend — especially in smaller schools, where 30 infected children may amount to far more than 2% of the student body.

For example, at Soldier Hollow Elementary School, a charter school in Wasatch County, 30 cases meant 1 in 10 students would have to be diagnosed with COVID-19 before triggering required school-wide testing.

The school organized voluntary testing in November after learning that a large number of students and teachers had fallen ill; Soldier Hollow ultimately found 37 active cases altogether, meaning COVID-19 had infected about 1 in 8 students who attend.

Rather than quickly isolating a small number of positive cases among students before the virus spread to other kids — as Test to Stay was meant to do — testing at this school simply confirmed how widely the coronavirus had already spread.

The higher threshold “created a massive gap in the triggering of Test to Stay in elementary schools,” Hersh said. “What we had then was the inability to activate our testing mitigation strategy which is our primary school covid mitigation strategy this year.”

Weiler, the Woods Cross lawmaker who sponsored the 2021 bill that codified Test to Stay, acknowledged that legislators and public health officials were at odds over where the threshold should stand.

“I don’t think any public health official thought it was a good idea to go with higher thresholds,” said Dr. Angela Dunn, who leads the Salt Lake County health department and was the state epidemiologist when legislators changed school testing rules.

“It’s much too late. As we saw, Test to Stay got quickly overwhelmed the moment we started with school, and that’s because you were unable to prevent the spread,” Dunn said. “Instead of having embers, you already had a wildfire.”

Dunn said she and other health experts warned lawmakers that the new threshold would make the virus harder to contain. Health experts were ultimately willing to split the difference and compromise at 1.5% — but legislative leaders wouldn’t budge, insisting that anything below 2% would result in too much disruption to in-person learning, Weiler said.

At one point, Gov. Spencer Cox threatened to veto Weiler’s bill over the threshold disagreement, but Weiler said Senate President Stuart Adams talked him down.

“Most reasonable people have come to realize that shutting down our schools even temporarily was hurtful to our children,” he said — although Test to Stay calls only for testing and was designed to help prevent shutting schools down.

Utah lawmakers banned schools from requiring masks, allowing freer transmission before testing kicked in

Since the pandemic began, health experts have called for a “layered” prevention effort: a combination of masking, testing, ventilation and social distancing. No single measure provides perfect protection on its own, but in early 2021, many of them were in place at Utah schools; masks were required in classrooms statewide until the final two weeks of spring term in 2021.

But Utah legislators had passed a law last session that forbid schools from requiring masks after that. So when schools opened in the fall, while the delta variant was circulating, masks were required only at a few districts, under local government work-arounds.

“Everything is different in the context of universal masking,” said Hersh, who previously has noted that the original version of Test to Stay was designed to work in combination with mask requirements. That’s what kept the virus from spreading before cases signaled an outbreak that triggered testing.

“I don’t think public health [officials] ever thought it was an intervention that, by itself, was going to stop outbreaks from happening,” agreed Mary Hill, an epidemiologist for the Salt Lake County Health Department.

Forbidding mask mandates also “put schools in a hard place,” said Alex Drungil, COVID-19 program lead at the Bear River Local Health Department, as administrators had to balance both parents who were opposed to masks and those who wanted their children to keep wearing face coverings.

Utah stopped requiring testing for extracurriculars, which let cases go undetected

Before Test to Stay came Test to Play: required testing every two weeks for students in sports and other extracurriculars, initially implemented to salvage the state’s high school football playoffs but applied to other activities.

The rule, implemented at 127 public high schools from November 2020 to March 2021, ensured that thousands of students were regularly tested regardless of the case numbers at their schools.

This surveillance uncovered cases that could prompt Test to Stay events until March, when the legislature voted to exclude Test to Play results from cases counting toward the 2% threshold.

“Any student involved in sports or any group that had a performance, they had to be tested at least once every two weeks,” said Aaron Jarnagin, principal of Tooele High School.

This program was “difficult from an administrative standpoint,” Jarnagin recalled. One of Tooele’s vice principals and the athletic director had to leave their normal duties to provide this testing two days a week. The district also hired two new part-time employees to assist with testing.

Still, Jarnagin said, case numbers at Tooele High School were much lower during the Test to Play trial period – when the school also had a mask requirement – than in fall 2021.

Regular testing with rapid antigen tests can reduce in-school transmission at a similar degree to PCR testing, said Divya Vohra, an epidemiologist at the research organization Mathematica who authored a report on school testing. “Routine testing buys you the advantage of identifying all of those asymptomatic people who would otherwise go undetected,” she said.

Both Hill and Hersh said Test to Play had a benefit beyond the test results. “There’s a lot of people that feel that it promoted safer behaviors and … using greater care and caution … because they’re going to get tested frequently,” Hersh said.

Some districts strove to provide free testing but others were uninterested

Even without Test to Play in place last fall, about 100 districts and individual schools still did preemptive testing for students and staff, by requesting supplies from the Utah Department of Health.

The Park City School District requested a total of 18,000 tests over the course of the semester. But most of the 32 districts or individual schools requested less than 1,000 tests. And several individual schools requested just one box, which held 40 tests. That was enough to test 20 students two times, as recommended by the Food and Drug Administration.

Park City schools wanted to be “proactive,” said Mike Tanner, the district’s chief operations officer. At any given time, Tanner aims to have at least 5,000 tests on hand, enough for every student to be tested once. The district has also maintained a testing center that was “accessible to any student or staff member” who wanted a test for any reason.

Testing numbers at Park City School District ranged from about 1,500 tests a week to a couple hundred tests a week, Tanner said. Using its inventory, this district also ran Test to Stay events at schools approaching the 30-case threshold, without requesting assistance from the state testing team.

Canyons School District similarly set up a drive-thru testing clinic at its district office, using 8,000 tests requested from the state during the fall 2021 semester. “This was free for students and employees — but we did not turn anyone in the community away if they needed a test,” said Canyons communications director Jeffrey Haney in an email.

The Bear River Local Health Department went even further with preemptive testing by conducting “classroom Test to Stay events” in local elementary schools when an individual classroom had two or three cases. This classroom testing was “less disruptive” than schoolwide testing, Drungil said, as students went to get tested at designated mobile sites rather than taking time out of school hours.

No elementary schools in the Bear River department’s purview hit the threshold for a schoolwide Test to Stay event during that fall semester.

Testing has become politicized, leading to low opt-in rates at some schools

School testing is most effective when the vast majority of students and staff buy into the program, experts say. “If you’re not getting enough participation, you’re just not getting a lot of payoff from those testing strategies,” Vohra said.

ABut as COVID-19 prevention measures have become increasingly politicized across the U.S., that climate has led some parents and school staff to view school testing as a waste of time or even as an infringement upon their rights.

At Park City School District, administrators faced a “significant minority” who felt “that their rights were being trampled on,” said Tanner, the district’s chief operations officer. Parents who opposed masks and vaccines have also opposed testing, as mask mandates in Utah schools were lifted.

“It’s unfortunate that school districts were the face of the governments in all of this, when in fact, we’re just reacting to the county and state and federal mandates,” Tanner said.

The reception was similar at Tooele High School, Jarnagin said. Some people were “super happy” to have the opportunity to get tested, while others “thought it was a waste of time and inconvenient.”

In Park City, one family sued the district, which at the time was requiring students to test every two weeks. And at Oakcrest and Soldier Hollow elementaries, only 51% and 29% of students were tested, respectively, when Test to Stay was triggered.

The best way to address such issues is through “one-on-one conversations” with parents who have concerns, said Leah Perkinson, an expert on school testing programs at Brown University’s School of Public Health.

But this type of individual communication “is what takes the most time,” and time is hard to come by for administrators already managing a variety of pandemic challenges, Perkinson said.

A possible snag: The drawbacks of rapid antigen tests

Test to Stay may have also suffered from the state’s choice to rely solely on rapid antigen tests, the same type of tests that are now widely available in pharmacies for use at home.

While these tests are much cheaper and more convenient than PCR tests, which are processed in laboratories, antigen tests are less accurate: they may provide false negatives, meaning a negative test result shows up even though the person who used it is actually infected with the coronavirus.

To reduce the risk of false negatives, the FDA recommends testing twice within a span of three days for Abbott BinaxNOW tests, the brand used in Utah schools. Experts also say that timing is important: Because these tests require a high level of coronavirus in someone’s body to identify infection, rapid tests may be less accurate in the first days after exposure.

For these reasons, modeling studies suggest that rapid tests are most useful in school settings when students are tested regularly. Recommended regimens include testing twice a week (such as every Tuesday and Thursday), or twice within two days (such as Monday and Tuesday every two weeks).

“If you test everybody on a Monday, there are some folks who are at the very beginning of their infection, and they’re going to test negative on Monday,” Vohra said. “But if you test them again, on Tuesday, they’ll test positive on Tuesday.”

For schools that already have high transmission in their communities, repeat testing is particularly important for catching all student and staff cases, Vohra said.

In Utah, however, students were tested just once, in isolation – and a negative result was considered sufficient evidence for returning to school, typically without a mask or other mitigation measures.

What’s next for mitigation in Utah schools?

Utah wasn’t the only state where school testing has struggled, said Aspinall, the Arizona State University expert. The omicron variant drove record case numbers across the country and rapid test supplies dwindled, even as the CDC finally endorsed Test to Stay as an official part of its school COVID-19 guidance in December.

Since then, however, tests have become more widely available. “We shouldn’t base our decision on whether Test to Stay is the right way to go based on the four weeks from the end of December to the end of January,” Aspinall said.

Aspinall and Perkinson both recommended that, rather than ending Test to Stay programs, schools prepare for future surges by stocking up on rapid test supplies. California, for example, plans to maintain capacity for at least 500,000 PCR and antigen tests a day – including ongoing testing in schools – as part of its plan to treat COVID-19 as endemic.

But Utah’s higher thresholds for triggering Test to Stay could remain a problem, Hersh said — especially as the state shifts testing to private providers, closes free drive-through sites, and recommends that only certain high-risk and symptomatic people get tested.

“If far fewer people seek testing for an illness, even at the same threshold you’d be unaware of [an increase],” he said.

Even with the lower thresholds, continuing any level of testing would still help to catch COVID-19 cases in schools. At the Davis School District — which had four Test to Stay events in elementary schools during fall 2021 — testing “identified the unknown positives in the school and slowed the transmission of the virus,” said community relations supervisor Shauna Lund in an email.

Tanner, at the Park City School District, said that he would like to see more unified communication from state and local agencies. Trying to understand new guidance from the CDC, the Utah health department, and his individual agency was “a never ending puzzle,” he said.

Similarly, the new Test to Stay bill passed in late January makes it harder for schools to shift to remote learning during surges, requiring approval from state leaders for such shifts. The additional bureaucratic layers required will “significantly slow down the process” of school decision-making, said Jarnagin, the Tooele High School principal.

“If we have another jump in numbers, it’s just gonna be chaotic and catastrophic because of the time and steps required” for mitigation measures to be enacted, Jarnagin said.

Without a spike, however, Dunn said health officials likely will try to handle coronavirus outbreaks in schools like some other illnesses, such as whooping cough (pertussis), measles and norovirus — “where we’ll test and treat those individual classroom outbreaks.

“We know when there’s several kids in a classroom that have pertussis, and we take mitigation measures based on that — and that’s where we’re going to get with COVID, too,” Dunn said.

— Tribune reporter Bethany Rodgers contributed to this report.