What Missouri schools learned the hard way about rapid Covid testing

What Missouri schools learned the hard way about rapid Covid testing
·8 min read

Early in the tumultuous 2020-21 school year, Missouri officials made a big gamble: They set aside about 1 million rapid Covid tests for the state’s K-12 schools in hope of quickly identifying sick students or staff members.

The Trump administration had spent $760 million to procure 150 million rapid-response antigen tests from Abbott Laboratories, including 1.75 million allotted for Missouri, telling states to use them as they saw fit. Nearly 400 Missouri charter, private and public school districts applied. Given supply constraints, each was offered one test per person, according to interviews with school officials and documents Kaiser Health News obtained in response to a public records request.

What began as an ambitious plan landed with a thud. Few of the tests were used; according to state data updated in early June, schools reported having used just 32,300.

Missouri’s effort is a window into the complexities of Covid testing in K-12 schools, even before the highly transmissible delta variant of the coronavirus surged through.

The spread of the delta variant has mired communities in emotional fights about how to safely send children — most of whom are unvaccinated — back to classrooms, particularly in states like Missouri, which has been bedeviled by a high aversion to mask mandates and low vaccination rates. As classes begin, once again schools must weigh testing and other strategies to limit Covid-19’s spread — potentially without a deep supply of test kits available.

Missouri educators described the testing, which began in October, as a blessing for having rooted out infected people and given teachers peace of mind. But its logistical challenges quickly became clear, according to interviews and documents obtained by KHN. Dozens of schools or districts that applied for rapid tests listed just one health care professional to administer them. The rapid tests initially were set to expire after six months, so officials were reluctant to order too many. And some worried that the tests would deliver inaccurate results or that on-site testing of people with Covid symptoms might spread infection.

“We were nervous” about sick kids’ being on campus, said Kelly Garrett, executive director of KIPP St. Louis, a charter school with 2,800 students and 300 staffers. Elementary school students returned in November. It reserved its 120 tests for “emergency” situations.

Related: "School nurses here are facing a moral dilemma, because the protocols that are in place and coming from the state don't align with their values," one expert said.

Robert Milner, principal of Hope Leadership Academy, a charter school in Kansas City that shipped dozens of tests back to the state, said, “Schools that don’t have a nurse on-site or any kind of medical staff on-site, it’s just not as simple.” Milner said the school was able to mitigate Covid-19 with measures like temperature checks, a mask requirement, physical distancing and even the removal of air dryers in bathrooms. In addition, “I have other options that I can send my families to” in the community for testing.

Lyndel Whittle, a public school superintendent, wrote in one district’s application for tests, “We have no plans, nor is it our job, to administer this test to everyone.” The district, Iberia R-V, requested 100 rapid tests in its October application, enough to provide one to each staff member.

“We're a school, not a healthcare provider,” Whittle wrote.

‘We weren’t shutting down’

As the limits of remote learning became clear last year, officials pressed for a return to school. Gov. Mike Parson at one point said that children would inevitably contract the virus at school but that “they’re going to get over it.” Now, even as childhood Covid cases rise because of the delta variant, districts nationwide are increasingly under pressure to return to full-time classroom instruction.

Testing in K-12 schools generally has been limited, experts said, despite the huge investment in rapid antigen tests. More recently, the Biden administration distributed $10 billion through the American Rescue Plan to increase routine Covid screening in schools, including $185 million for Missouri.

Missouri is establishing a program for K-12 schools to regularly test people without symptoms, relying on a contract with the biotech company Ginkgo Bioworks, which provides testing materials, training and staffing. As of mid-August, only 19 institutions had expressed interest, said Lisa Cox, spokesperson for the state Department of Health and Senior Services.

Unlike Covid tests that use a polymerase chain reaction technique, which can take days to deliver results, rapid antigen tests return results within minutes. The trade-off: Studies have shown they are less accurate.

Still, for the president of the Missouri State Teachers Association, Halley Russell, a high school teacher in Jackson, it was a relief to have rapid tests, and she wished they’d had them sooner. Her district, Jackson R-2, applied in December and began using them in January, months after schools reopened.

“The timeline was just hard. We couldn’t rapid-test students we thought” could have Covid-19, she said. “Some of them just quarantined.

“Ultimately, I think, there was a level of anxiety the entire time, because we were face to face. We weren’t shutting down,” said Russell, whose classroom required masks. “Testing just gives you some control over things you can’t control.”

Allison Dolak, principal of Immanuel Lutheran Church & School in Wentzville, said the small parochial school had the means to use rapid Covid tests for students and staffers — but it took ingenuity.

Dolak said applying for tests was a “no-brainer” to help keep the doors open.

“There would have been so many kids that had to online-learn had we not had those tests,” she said. At times, the suburban St. Louis school had to call on parents who were nurses to administer them. Dolak even administered a few herself in the parking lot. State data as of early June showed that the school received 200 tests and used 132. It didn’t require masking.

Many schools indicated that they intended to test only staff members, according to applications obtained by KHN. Missouri directed schools at first to use Abbott’s rapid tests on symptomatic people, which further limited testing.

Arguably, some of the reasons testing was limited aren’t bad — in interviews, educators said they curbed infections by screening for symptoms and requiring masks. Currently, Missouri authorizes testing on symptomatic and asymptomatic people.

“In the K-12 space, there really has not been that much testing,” said Dr. Tina Tan, a professor of pediatrics at Northwestern University’s Feinberg School of Medicine. “It really has been more that kids have symptoms screened before they’ve gone to school, and if they become symptomatic, then they’re tested.”

At least 64 schools and districts that received tests hadn’t administered a single one as of early June, according to state dashboard data that schools self-report.

Others that applied didn’t follow through on their orders or decided against administering tests, according to interviews and documents obtained by KHN.

One was the Maplewood Richmond Heights district in St. Louis County, which directed people away from schools for testing.

“While the antigen test is decent, there were some false negatives,” Vince Estrada, the director of student services, said by email. “For example, if a student had been exposed to someone with COVID-19, and tested negative with the antigen test at school, we would still require them to get a PCR test.” Space for testing and availability of nurses were also issues, he said.

Molly Ticknor, executive director of the Show-Me School-Based Health Alliance of Missouri, which focuses on access to health services at school, said, “Many of our school districts don’t have capacity to store the tests, to manage the testing.”

‘A lot’ of tests returned unused

Sherry Weldon, administrator of the Livingston County Health Center in northwestern Missouri, said the public health agency ran tests for personnel in county schools, both public and private. “None of the schools want to take that on themselves,” she said. “They just were like, oh, God, no.”

Weldon, a registered nurse, said that when the school year was over, she shipped back “a lot” of unused tests, although she has since reordered some to offer rapid testing to the public.

Cox, the state health department spokesperson, said that as of mid-August the state had recouped 139,000 unused tests from K-12 schools.

Recouped tests would be redistributed — the shelf life of Abbott’s rapid antigen test has been extended to one year — but officials aren’t tracking how many have been, Cox said. Schools aren’t required to report the number of expired antigen tests to the state.

Mallory McGowin, spokesperson for the state Department of Elementary and Secondary Education, said, “Absolutely, there have been tests that have expired.”

Health officials also sent rapid tests to long-term care facilities, hospitals and jails, among other locations. As of mid-August, the state had distributed 1.5 million of the 1.75 million antigen tests it got from the federal government. After accounting for tests that K-12 schools didn’t use, the state had shipped them 131,800 tests as of Aug. 17. “It quickly became clear,” Cox said, that “the tests we had pushed out were not being fully utilized.”

Asked whether schools were equipped to handle testing, McGowin said having such resources was a “real opportunity” but also “a real challenge.” But “at the local level, there’s only so many people to help with Covid protocols,” she said.

Dr. Yvonne Maldonado, chief of Stanford University’s pediatric infectious diseases division, said school Covid testing could “make a big difference.” However, the more important strategies to limit spread are masking, increased ventilation and vaccinating more people.

“Testing is more icing on the cake,” she said.

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