Summarizing Implementation Support for School-Based COVID-19 Testing Programs in Southwest American Indian Communities

Abstract

Context:

American Indian communities have been disproportionately affected by the COVID-19 pandemic, with school closures exacerbating health and education disparities.

Program:

Project SafeSchools’ COVID-19 school-based testing program utilized federal and state funding to provide weekly pooled testing with follow-up rapid antigen testing to students and staff from the White Mountain Apache Tribe and Navajo Nation.

Implementation:

The project provided partner schools with training and continual logistical and technical support to aid in school-based testing and adherence to state and local reporting requirements.

Evaluation:

Using the Exploration, Preparation, Implementation, and Sustainment framework, we identified facilitators and barriers to successful program function. While community support and buy-in were essential for successfully implementing school-based testing in these communities, communication, school staff turnover, and funding are among the most significant challenges.

Discussion:

Community partnerships in American Indian communities involving schools and local health authorities can successfully implement testing protocols by remaining flexible and working together to maintain strong lines of communication.

Introduction

The first case of SARS-CoV-2 in the United States (US) was detected on January 20^th, 2020. By March 30^th, all but one public school district in the US was closed for in-person learning.¹ US school-age children experienced varying educational settings as the pandemic unfolded, from virtual learning to hybrid approaches, and a return to in-person learning. Disruptions to instructional routines have resulted in extensive learning loss. Students facing significant educational disparities, including racial and ethnic minority youth and students in rural and reservation communities, have been particularly affected.^2–5 Furthermore, there have been notable increases in mental distress in students, which compounded learning loss.^3,4 Unfinished learning caused by the COVID-19 (hereinafter, COVID) pandemic is estimated to have lifelong and worldwide consequences for youth.^6,7

Although school closures and virtual learning have impacted youth nationally, American Indian and Alaska Native (AI/AN) youth are being left behind. Before the pandemic, AI/AN youth were more than twice as likely than their white peers to drop out and not finish school.⁵ Research indicates that this gap is increasing in the wake of the pandemic.^4,8 Additionally, schools serve as a critical source of wraparound support services, including providing reliable food access for many AI/AN students. More than 98% of students in the largest districts on the Navajo Nation and the Fort Apache Indian Reservation qualify for free and reduced-fee meals.⁹ AI/AN youth have endured the largest parental/caregiver loss burden compared to all other racial and ethnic populations in the US.¹⁰ For those who need support, schools serve as an essential outlet for AI/AN youth seeking mental health-related services professionally from a counselor or informally from school staff.^11,12 School connectedness, which includes a sense of belonging and feeling supported at school, has also been identified as a protective influence on youth mental health even after controlling for marginalization and discrimination.¹³ Disruptions to the educational systems in reservation-based communities, combined with the pandemic’s ongoing toll, have profoundly affected AI/AN youth’s mental health and academic self-efficacy.¹⁴

With the urgent need to reopen schools for in-person learning, the CDC, in July 2020, released recommendations for schools that wanted to implement in-person learning.^15,16 Their guidance, supported and promoted by the American Academy of Pediatrics, incorporated layered mitigation strategies, including social distancing, cohorting, universal masking, handwashing, sanitization, temperature screening, and home-based symptom screenings.^17,18 In December 2021, the CDC updated its guidance to include school-based testing protocols and authorized vaccinations for those 12 years and older.¹⁶

Early school-based COVID testing programs were instrumental in providing evidence for the utility of these approaches alongside other mitigation efforts. Early testing programs demonstrated reduced anxiety about in-person learning among parents and school staff and reduced in-school transmission by up to 50%.^19,20 A systematic review of school-based testing programs reported that cumulative school-based transmission rates among students from December 2019 to September 2020 were low (i.e., 0.15%).²¹ This review and others suggested that while school transmission is related to community transmission, schools are no riskier for COVID infection than at home or out in the community.^16,19,21,22

Recognizing the utility of school-based testing, the National Institutes of Health’s Rapid Acceleration of Diagnostics Underserved Populations (RADx^®-UP) program awarded $33 million to COVID testing projects in underserved communities. This paper describes developing and implementing an approach to support COVID surveillance and reflex testing strategies in partner schools funded under the RADxUP initiative (OT2HD107543) to facilitate a return to in-person learning.²³ We summarize lessons learned, provide best practices to inform future school-based testing programs, and illustrate the importance of community partnerships for promoting health equity. ²⁴

Methods

We chronicle our approach using the EPIS framework. The EPIS framework documents four phases integral to successful implementation including Exploration, Preparation, Implementation, and Sustainment.^25,26

EPIS: Exploration Phase

Our work began in partnership with the White Mountain Apache Tribe (WMAT) in east-central Arizona. The WMAT community is located on the Fort Apache Reservation and is home to more than 15,500 tribal members.²⁷ Of those who live on the reservation, 37% are under the age of 18, with 46% living below the poverty line.²⁸ Like most schools across the country, those on the reservation were closed entirely through December 2020. During this time, Tribal leadership endorsed support for a school-based testing method through a tribal resolution (i.e., a policy declaration). Following the passing of the resolution, our team at the Center for Indigenous Health (CIH), with the local Indian Health Service (IHS) and the Tribe’s public health team began exploring the feasibility of implementing COVID testing in schools. Though initially, funds were limited and testing supplies were extremely scarce, by the start of 2021, CIH received pilot funding from the Rockefeller Foundation and RF Catalytic Capital, Inc. The pilot funding supported school-based COVID testing programs for two WMAT-serving school districts (four schools). Prior to implementation, this initial work was reviewed and approved by the Tribal Council, Tribal Health Board, and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (IRB No: 14911/MOD 1874, Approval Date: December 21, 2021).

The pilot program lasted from January 2021 through May 2021. The initial testing strategy used by the two school districts included twice-weekly asymptomatic rapid antigen tests administered by school personnel to school staff and students who wished to participate and who provided written consent. During piloting, CIH orchestrated the procurement and distribution of supplies, developed communication materials, consulted with school leaders on implementation strategies, and analyzed and disseminated data. Schools implemented all testing protocols and engaged in contact tracing in partnership with IHS and the Tribe. IHS and the Tribe also advised schools more broadly on mitigation efforts and supplied critical personnel to assist with testing logistics. Piloting the program helped to build trust with partners, facilitated the delineation of roles across agencies, and supported buy-in from the local community.

EPIS: Preparation Phase

The end of the pilot program established a desire within the WMAT community to grow the program to other districts and indigenous communities. Funding from RADx-UP in April 2021 allowed the program to expand to Navajo Nation (NN). With approval from the Navajo Nation Human Research Review Board, testing was extended to all schools serving three large service areas on the Navajo Nation. With the most enrolled members in the US, the NN spans northeastern Arizona, northwestern New Mexico, and southeastern Utah.²⁹ Approximately 144,000 people live on the Navajo reservation, with 27% under 18. Almost half of Navajo children (46%) live in poverty.³⁰ Testing continued for pilot schools and included all other WMAT-serving schools. In total, 27 schools participated in the testing program during the early days of the 2021–2022 school year (Table 1).

Table 1.

Tribe	Number of Schools within District34,35	Total Student Population34,35	Percentage of Students on Free/Reduced Lunch9	High School Graduation Rate 34,35
Navajo Nation
District 1	5	1,386	82–98%	70%
District 2	3	990	98%	68.5%
District 3	7	3,198	94–98%	80.7%
BIE School	1	62	No data	90%
White Mountain Apache Tribe
District 1	5	2,157	98%	75.6%
District 2	1	133	98%	N/A
BIE School 1	3	373	98%	68%
BIE School 2	1	140	98%	N/A
Private School	1	170	No data	N/A

While the pilot program focused on testing individuals using rapid antigen tests multiple times per week, it was deemed too cost-prohibitive and labor-intensive for many schools. Instead, all schools participating in the expanded program selected a cost-effective pooled surveillance approach for the 2021–2022 school year. This approach allowed groups of 5–25 students and staff to test together using ultrasensitive polymerase chain reaction (PCR) tests.

Prior to testing implementation, CIH team members met with each participating school and/or district. These meetings focused on introducing the program to staff, creating operational testing policies and procedures (detailed in the EPIS: Implementation Phase), drafting an inter-agency Memorandum of Understanding, and obtaining CLIA waivers. Schools selected a testing day, designated people to facilitate testing, and identified testing location(s). CIH team members also set up each school’s online testing portal, which was used for tracking and reporting test results to the state’s public health department. Portal activation included granting access to school and public health personnel, arranging courier and laboratory services, and placing the first order of test supplies. To build ongoing community collaborations, presentations describing testing support were also delivered to Department of Diné Education members, tribal mitigation teams focused on infection control, and Community Action Boards in both communities.

Following the school’s identification of testing personnel, members of the CIH team provided a 90-minute in-person or virtual training on conducting testing at their school. Training focused on proper swabbing techniques and a guided online portal tutorial. The CIH Health Communications Team developed new informative brochures related to testing, evidence for testing, testing logistics, and early results of school-based testing programs. These resources were provided to schools for dissemination in an effort to explain processes and generate participation buy-in.

EPIS: Implementation Phase

At the beginning of the 2021–2022 academic school year, schools distributed and collected testing consent forms from their students and staff, who were all eligible to participate. On the predetermined pooled testing day, participating students and staff met in a central location (e.g., a gym each pooled group would travel to for testing), or testing staff (usually the nurse and an administrator) would visit each classroom to conduct testing. The day after pooled testing, testing staff monitored their school’s test portal for any positive or indeterminate pools identified by the laboratory. Members of positive or indeterminate pooled groups would be individually tested using a rapid antigen test kit per follow-up protocol (Figure 1). Testing staff reported the results of each rapid test using the online portal, which were then directly uploaded to state reporting databases. Individuals with positive tests were isolated and sent home. Local IHS partners monitored the portals and provided follow-up support to families of positive individuals, including additional services needed and contact tracing. By mid-year 2021, several districts in WMAT and NN requested that rapid testing be expanded to include extracurricular activities.

Figure 1.

Example of school district’s testing protocol

During the first few months, CIH team members helped schools with registering samples, shipping samples to the laboratory, and reporting results to the state. Additional and ongoing ad hoc support was provided by phone and email to help schools with technical issues. Weekly COVID school surveillance dashboards were developed (Figure 2) and shared with each district/school’s leadership as a supplementary tool. Dashboards applied testing information captured by the portal and synthesized it into meaningful measures of testing uptake and disease burden. Weekly/biweekly conference calls were established for each district/school to cultivate a community of practice. During calls, barriers to the testing program were addressed, facilitators of implementation and general updates were shared, and community-specific COVID surveillance data were reviewed. At times of high community transmission, calls also served as a space to help to inform a district’s decision on whether to continue with in-person instruction or revert to a stage of online-only or hybrid learning.

Figure 2.

Example of district-wide weekly school-based COVID-19 testing dashboard

*The term ‘Pools’ refers to 5–25 individual test takers who participate in an initial round of group testing.

+ ‘Cases’ refers to individuals who have been identifed as having contracted COVID-19 by means of follow-up rapid antigen tests.

EPIS: Sustainment Phase

In October 2021, pooled and rapid testing supplies for all schools were transitioned from grant funding to funds provided by the State of Arizona. Federal support ensured that schools could continue testing through funding to states. CIH has continued to serve as implementation support to schools as an interagency navigator and to provide ongoing technical assistance as needed.

Contextual Findings

Pooled testing was a new public health initiative implemented during extraordinary circumstances as reservation schools attempted to re-open to students. This project was impacted by ongoing internal and external influences that complicated the implementation of pooled testing, including risk mitigation guidance that evolved quickly based on local, tribal, and federal public health guidelines. This contributed to confusion and frustration among school staff regarding best practices and subsequently affected communication with the families and communities they serve. Moreover, the recommendation to test without supplemental personnel support from other organizations added additional responsibility, reducing buy-in among school leaders and staff. School personnel turnover and absences presented unique challenges as onboarding and re-training took precious time away from already busy schedules. Due to rurality, weather, and reduced cell phone reception, missed pick-ups and samples arriving outside of their viability window were common. Fluctuating laboratory processing times also contributed to the overall time burden of the testing program, with delays in pooled results further delaying rapid testing and the quarantining of sick students and staff. Technology issues related to hardware, software, and internet connectivity increased frustration. The most demanding challenge was the time burden of conducting the tests and facilitating mandated reporting.

During the height of the Omicron variant in Arizona (November 2021 – January 2022), many schools increased pooled testing to twice weekly.³¹ They also required additional rapid testing of students participating in extracurricular activities while continuing with established COVID mitigation protocols. These efforts allowed one large partner district to remain open, despite widespread demands to close. They demonstrated to the community that there was no increased COVID risk from staying in school. However, other schools struggled with the added burden of increased testing cadence and paused in-person learning. Ultimately, schools had to balance what was most beneficial from an infection control perspective, what was most constructive from an academic perspective, and what was feasible from their own internal personnel capacities. Finally, an uncertain funding horizon for the program left many districts unsure of how long their testing program would last and what they might do to sustain efforts internally.

Despite these challenges, testing was widely viewed by tribal community members, including teachers and staff, as an important mitigation effort to ensure the community’s safety and keep schools open for in-person learning. AI/AN people are culturally deeply rooted in a more collective approach to sustaining well-being. This commitment led to a unique community response in which the implementation of risk mitigation strategies to prevent harm to others is more acceptable and has become part of social responsibility in these tight-knit reservation communities. The sovereignty of Tribal Nations was also critical. Due to the swift policy action taken by both Tribal Nations during the onset of the pandemic, tribal governments played an integral role in deciding how reservation schools would re-open to students. A shared responsibility to protect community members and protect Indigenous life ways largely contributed to compassionate communication among partner organizations, strengthening interprofessional collaboration and problem-solving. Further, school leaders and staff charged with implementing the testing program within their schools came from the same communities as their students. This value of kinship, often a key trait of indigenous communities, contributed significantly to the success of embedding COVID pooled testing in reservation-based schools.

Recommendations

Public schools host large groups of vulnerable pediatric populations for extended periods of time. When planning for future pandemics, school leaders must be part of planning and responding during public health emergencies. Based on our experience and process, we present several recommendations for implementing future school-based testing programs. First, creating and maintaining open lines of communication between schools, local public health agencies, and community partners is critical. Regular (e.g., weekly, bi-weekly) virtual or in-person meetings to discuss policy and responses to health issues that arise are essential to effective communication. Second, while communication was vital, the relaxation of HIPAA and FERPA laws allowed a more open flow of information that supported tailored responses to health concerns among students and staff. Third, schools must receive additional personnel support to facilitate their protocols and responses. It is also crucial that this support comes from within the local community to the greatest extent possible. Local personnel are familiar with the community and context and can more easily integrate into the school setting and facilitate expeditious use of the additional resources. Fourth, any new mitigation effort must generate local buy-in. While partnerships take time to create, funding agencies should leverage existing partners in the area, many of whom have spent years developing relationships, to support new initiatives. The fifth and final recommendation is to develop data infrastructure alongside the distribution of resources which is critical to ensuring transparency and instilling trust.

Conclusion

Since the spring of 2020, school leaders around the globe have been required to make decisions on student and staff safety that fall outside the bounds of traditional educational expertise. School closures due to the pandemic have had a devastating impact, particularly for AI/AN communities. Our team supported some of the most disadvantaged schools in the US with their efforts to mitigate COVID and keep students enrolled in in-person learning. School-based COVID testing programs are intensive, particularly in remote settings like reservation-based communities. They require multiple layers of communication, support, and adaptability to succeed. Mobilization of both internal staff (e.g., teachers, administrators) and external agencies (e.g., IHS, tribal, local volunteers) was critical to the development and implementation of the testing programs.

This project ultimately demonstrated how critical multi-sectorial partnerships are in implementing and supporting infectious disease testing programs in schools. While we showed that infection control and mitigation efforts are possible, implementation time and funding considerations must be accounted for in future rollouts. Our results and recommendations are consistent with the lessons learned by early adopters of testing programs, as illustrated by The Rand Corporation and Mathematica reports.^19,20 Future projects should consider including a cost-benefit analysis to better inform states and local communities of the financial requirement of instituting a school-based testing program. The next global health crisis could be right around the corner. We owe it to our children and community members to prepare for it by working cooperatively.

Implications for Policy and Practice.

• School-based infectious disease surveillance programs are feasible in American Indian/Alaska Native communities and may be used in the future to keep students and staff in the classroom.

• Considerable implementation support is needed to adhere successfully to robust school-based surveillance testing protocols.

• Consistent external funding sources (i.e., tribal, state, and federal programs) must be readily available for schools to continue programming in response to public health emergencies.