Reopening Schools During COVID-19 Pandemic through Community Engagement and In-school Testing

·         A brief description of your local health department, including location and the demographics of the population served in your community.

Houston Health Department (HHD) is a full-service health department located at 8000 North Stadium Drive Houston, Texas. The department services benefit all Houston residents especially those most in need, such as low-income families, the elderly, and minority populations. It serves over 2.2 million residents in the City of Houston (CoH).

·         A description of the public health issue.

With the emergence of COVID-19 and attendant global chaos, in-person learning was stopped in schools within the United States during the spring of 2020. After a year of virtual school learning, attendant adverse psycho-social effects of isolation alongside other mental health challenges, need for students to return to safe in-person learning was echoed across various groups and communities. Public health interventions such as screening testing for COVID-19 and vaccination were activated for early detection of cases and prevention of spread. To keep the over 400,000 students and faculties in schools (K-12) within the CoH safe, a comprehensive in-school COVID-19 testing was implemented by the HHD through fundings received from the Centers for Diseases Control and Prevention (CDC) Reopening Schools grant.   

·         A description of the goals and objectives of the proposed practice.

Goal: To safely reopening schools and keeping them safely opened for in-person learning through COVID-19 Pandemic

Objectives:

1.    To provide free and accessible COVID-19 testing to schools

2.    To promptly detect cases of COVID-19 in schools especially among the vulnerable

3.    To rapidly respond to COVID-19 outbreaks in schools

·         The activities that were implemented for your practice.

A)   Planning phase:

i)              Stakeholders' engagement - school district management, schoolteachers, nurses, parents' community, social media influencers, student community, CDC Foundation 

ii)             Laboratory assessment and selection

iii)            School assessment for existing COVID-19 infection prevention and control strategies

iv)           In-school testing frequency determination

v)            Parental consent consent letter content and deployment strategy development 

B)   Implementation phase: The program implementation phase includes the following -

                         i.                Obtaining a one-time parental consent for each participating student to cover for all COVID-19 testing conducted on each student for the school year.

                        ii.                Consent is also obtained from faculty members (both teaching and non-teaching staff)

                       iii.                School nurses and field staff training on testing coordination

                      iv.                Development and distribution information, education and communication (IEC) tools

                       v.                Routine school visits (field staff deployment) for nasal sample collection, kit shipping, PCR testing and result sharing

                      vi.                Case investigation and contact tracing 24-hour open epi hot lines

                     vii.                Field outbreak investigation and implementation of control strategies

                    viii.                Technical support provided to schools for infection prevention with deployment of epidemiologists to schools to support nurses in implementing mitigation strategies.

C)   Results/Outcomes:

i)      HHD developed a multi-agency partnership

ii)     A private laboratory with lab site located within the CoH was engaged.

iii)    Surveillance screening testing and outbreak response testing

iv)   Antigen testing and Polymerase chain reaction (PCR) testing.

v)    A total of 471 schools (443 public and 28 private schools) were enrolled for testing

vi)   Over 107,000 PCR tests were conducted, and 62,636 antigen tests kits supplied 

vii)  Sixteen emergency drive-through clinics were set up in response to school outbreaks

viii) 1.5% COVID-19 cumulative positivity rate was observed

ix)   No school closure due COVID-19 outbreak from start of 2021/2022 school year till report writing.

D)   Project objectives, and if they were met.

Objectives:

1.    To provide free and accessible COVID-19 testing to schools - Over 400,000 students and 17,000 staff had access to free COVID-19 testing at their various schools through the HHD/Private lab PCR testing, HHD/DSHS/TEA antigen test kit supply programs. 

2.    To promptly detect cases of COVID-19 in schools especially among the vulnerable population HHD developed COVID-19 Vulnerability Indices which determined frequency of testing for each school, and through the surveillance screening was able to quickly detect surges in cases

3.    To rapidly respond to COVID-19 outbreak in schools: 16 rapid response drive-through testing sites were activated. Epidemiologists were deployed to provide technical support to schools with outbreaks; develop line lists of cases, review existing IPC measures and guide the implementation of control measures.

E)    The specific factors that led to the success of this practice.

a.    Stakeholders mapping

b.    Stakeholders engagement .

c.     Obtaining parental consent

d.    CDC funding for program activities

e.    Health department workforce development   

F)    The public health impact of this practice

1)          No COVID-19 pandemic-related school closure throughout the 2021/2022 school year.

2)    Low community transmission of COVID-19 due to on-going school testing/surveillance 

3)    Improved school health program linkage to other school-healthcare services such as dental health support, eye tests, vaccinations, and other social support.

G)   The level or type of community engagement included in your practice

The Program engaged both government and non-governmental agencies to ensure an effective and successful school COVID-19 testing/surveillance. The program utilized various levels of community engagement from individuals to groups, in-person and virtual engagement platforms such as social media.

All these stakeholders were engaged through all the program phases planning and design, implementation, and evaluation

·     The steps taken to address and reduce health inequities.

1)    Use of a model of vulnerability indices that assisted the identification of schools located within underserved communities/ZIP Codes

2)    In-school surveillance testing frequency was higher and prioritized in schools located within ZIP Codes with high COVID-19 transmission and low vaccine coverage these were mainly schools located within communities of color, African American communities, Hispanic communities and other minority population. 

3)    Priority was also given to schools caring for children with physical or mental impairment e.g. Avondale House (school caring for individuals with autism)

4)    Activation of emergency drive-through testing clinics in locations with sudden surge in cases enabling the testing of not only the students and faculty within the affected schools but also their household members. 

H)   Program and/or local health department website.

HHD School Testing Program

HHD School Testing News Release

New to the field of public health (and not just new to your health department) OR Creative use of an existing tool or practice

I. The Use of model of Vulnerability Index Tool: A vulnerability index tool composed of 4 parameters was developed and used in the prioritization of school for intervention. CDC guidance required that community transmission be factored in when considering test frequency and sampling design for school PCR testing.  To help differentiate levels of risk appropriate to the Houston area we developed a method using cumulative positivity rate and unvaccinated rate by ZIP Code as health measures.  In addition, we used COVID Community Vulnerability Index as a measure of socioeconomic status, to help target populations with a disproportionate burden of COVID and to account for potential equity concerns that lead to under ascertainment of COVID transmission.  The ZIP Code in which the school is located was used for ZIP Code assignation.  These were broken into categories using Jenks natural breaks and scored for each of the three community variables:  Positivity Rate by ZIP, Unvaccinated Rate by ZIP, and CCVI by ZIP.  The score for each ZIP Code was then summed. These were broken into three categories using Jenks natural breaks.  The three categories are High Risk, Medium Risk, and Low Risk, with schools having the highest total sum falling into the High-Risk category.  Schools falling in the Low Risk and Medium Risk groups were to test bi-weekly, while schools falling in the High-Risk group were to test weekly.

II. In-school Testing for COVID-19: Prior to the emergence of COVID-19, school-health programs have always included screening for non-communicable diseases like eye or hearing defects, skeletal deformities, malnutrition among students in schools, however, in-school screening for infectious diseases like COVID-19 is novel.

III. Creative use of an existing tool or practice: the HHD team made inventive use of the Mobilizing for Action through Planning and Partnerships (MAPP) tool in the planning and the implementation of the Reopening Schools Testing Program.  We conducted an assessment of the proposed plan for school testing at the design phase, identified strengths and challenges towards its implementation. We also assessed our Local Health Department System to identify and allocate resources needed for an effective implementation, worked with community partners/stakeholders to determine what the community health status was as regards COVID-19 testing and finally describe the various forces of change encountered and how HHD managed these forces to ensure schools within the CoH were safely reopened and remain reopened.   Below are the 4-level assessment explored and its application on the  school Testing program using the MAPP tool:  

Community Themes and Strength Assessments: The major challenge of the school community in the face of COVID-19 pandemic was first, the loss of in-person school learning with the need to reopen and stay open safely, while the pandemic continued. The critical need for affordable and accessible COVID-19 testing became imminent. With parents, students, and educators eager to resume in-person learning, HHD developed a plan to provide in-school testing (regardless of school districts' preference for either antigen or PCR test) to support the safe reopening of school.  

Local Public Health System Assessment: Like every other health department within the country, HHD workforce was stretched thin at the start of the pandemic. Assessment findings include inadequate manpower at HHD and an existing but suboptimal disease reporting system between ISDs and HHD. To address these findings, HHD partnered with CDC foundation to engage additional staff to serve as school liaisons. A local private laboratory was also engaged to provide PCR testing and a dedicate reporting mechanism created between the ISDs and HHD.

Community Health Status Assessment: COVID-19 transmission rate varied across communities/zip codes, There was disparity in the transmission rates, COVID-19 testing and vaccine coverage among the communities where the schools are located. Many of the ISDs and the schools did not have adequate manpower (required number of nurses) to conduct the PCR testing. HHD deployed point of care antigen testing, in-school and drive-through PCR testing in locations of greatest needs. Information and educational materials and outlets were also developed to provide information on vaccine availability. Field staff trained in nasal swab collection were also deployed to the schools.

Forces of Change Assessment: Some of the identified positive factors that were leveraged on to deliver on the project included the strong political /administrative will at HHD (HHD) and the school districts (ISD); supportive ISD authority and parent body. Funding from CDC, and Federal government was also very instrumental to the implementation.

Mobilizing for Action through Planning and Partnerships (MAPP) 

  Please provide a statement of the problem/public health issue.

COVID-19 caused by a novel coronavirus called SARS-CoV-2 is a highly infectious disease which readily spread in congregate settings like schools and campuses. Children of school age are known to incubate and transmit the infection more easily to older adults like parents, grandparents and teachers who may develop more serious complications from the disease because of underlying medical conditions.

At the height of the COVID-19 pandemic schools were closed to reduce the spread of the infection in schools and community. This led to the loss of in-person school learning for a whole school year with its attendant adverse psycho-social effects on students and educators.

What target population(s) is/are affected by the problem? Please include relevant demographics. – Students from kindergarten through 12^th grade alongside their teachers and other faculty members) were affected by the COVID-19 pandemic and the subsequent closure of the schools. The program aimed to ensure a safe reopening of the schools and keeping it safe through the pandemic.

What is the target population size – A total of 471 schools(443 public and 28 private) were targeted for the intervention. This list comprises the following:

1. HISD – largest school district within the State of Texas with 276 schools
2.  Aldine ISD – 65 schools
3.  Alief ISD – 46 schools
4. Spring branch ISD - 36 schools
5. Charter schools - 20
6. Private schools – 28

 What percentage of the target population did you reach?  Over 90% of the schools had testing support, IEC materials support  to 100% and technical support  to 100% of the schools.

 What are the structural drivers, or root causes, of the problem? What had been done in the past to address the problem?

Structural drivers:

 i.Congregate nature of school settings; with a range of 20-25 students in a classroom, breakfast and lunch taken with many classes meeting together in the same hall etc., the school premises serve a good transmission ground for COVID  

ii.Close sitting arrangement in circular pattern  

 iii.Sub-optimal classroom ventilation/air quality

 iv. Two-way hallway movement encouraged body contact   

What was done to address the problem:

i. Classroom sitting re-arrangement from circular to linear (uni-directional) table-chair arrangement -Social spacing introduced

 ii.One way hall movement was introduced to replace the two-way movement

 iii.Students were batched in groups for breakfast and lunch time

 iv.School was shut down

How does the practice address health inequities in your jurisdiction?

 What health equity actions were taken to address these health inequities?

There were inequities in access to COVID-19 testing among students, staff and parents based on their location, establishing in-school testing especially the Drive-Through testing spots brought testing closer to them. This contributes to bridging the gap in access to testing. Other actions that address health inequities in accessing COVID-19 services include the following

1)     Use of a model of vulnerability indices that objectively identified schools located within underserved communities

2)     In-school surveillance testing frequency was higher and prioritized in schools located within zip codes with high COVID-19 transmission and low vaccine coverage – these were mainly schools located within communities of color, African American communities, Hispanic communities and other minority population. 

3)     Priority was also given to schools caring for children with physical or mental impairment – e.g., Avondale House (school caring for individuals with autism)

4)     Activation of drive-through testing clinics in locations with sudden surge in cases ensuring the testing of not only the students and faculty but also their household members. 

What steps were taken to incorporate principles of health equity into the

planning and implementation processes for this practice?

To incorporate principles of health equity into this practice model, we used a health equity lens in planning, development, and implementation of the practice. This means intentionally looking at the potential positive and negative impacts of proposed practice on everyone with the goal to be inclusive, avoid bias and stigmatization, and effectively reach intended audiences, ideally with input from those intended audience. Some of the steps we took in this regard are listed below:

1.     Engagement of relevant stakeholders cutting across public health, state and district education boards, teachers, parents and students to obtain inputs, identify and address concerns, ensuring  health equity in the planning and implementation of the program. 

2.     HHD conducted intentional and objective assessment of all schools located in various ZIP Codes. Schools located within ZIP Codes of high COVID-19 transmission and low vaccine coverage (usually underserved communities) had teams of field staff testing deployed to obtain samples at a higher frequency than schools where transmission was lower and higher vaccine frequency.

3.     Intra departmental (HHD)collaboration with health education unit, communication and media unit, school health team in proactively developing targeted information education and communication (IEC) tools to counter misinformation especially among communities of color who expressed outright distrust in government and vaccines.

4.     Interagency collaboration with Texas Education Agency, Texas department of state health and human services to identify schools with preference for antigen testing only and subsequent supply of all these schools with their preferred testing kits. 

5.     Activation of COVID-19 vaccine clinics within underserved communities: Deliberate selection of schools in vulnerable and remote locations with high prevalence of COVID-19, low socio-economic status and schools with challenged students with health disparity.

Why is the current/proposed practice better? Is the current practice innovative? How so/explain?

 Is it new to the field of public health?

Is it a creative use of existing tool or practice?

The in-school PCR testing for COVID-19 conducted by HHD is both innovative and produced better results. While screening for non-communicable conditions like hearing or sight impairments is not new to the school community, introduction of a turn-key program; in-school sample collection of specimens for an infectious disease outbreak of the COVID-19 magnitude was new. All PCR test results were available within 24 hours of sample collection. This ensured that infected and detected students or staff did not return to class the next day to prevent further spread of the virus especially prior to the emergency use authorization of COVID-19 vaccine for all age groups. Other innovative aspects of the practice are as follows

1)     While stakeholders' engagement is not new in the field of public health, a better program outcome was achieved through active stakeholders' involvement and ownership from the design phase through implementation and evaluation.

2)     The active interagency collaboration among HHD, TEA and DSHS ensured all schools within the CoH were reached, with all public schools implementing at least one type of testing or both (antigen test kits and/or PCR testing)

3)     Engagement of the Parent-Teachers Organization provided the platform to share the science and practice behind the school testing program – allaying parents' concerns and fears thereby improving parental consent for students' participation and teachers' support and participation as well.

4)     The use of the model of vulnerability indices ensured schools located within ZIP Codes of high transmission and low vaccine coverage (minority populations/communities of color) had more frequent in-school testing compared with ZIP Codes with low transmission and high vaccine coverage thus ensuring equitable distribution of the School Testing Program resources.

Is the Current Practice innovative?

Yes, the practice is evidence-based making use of CDC guideline (CDC Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning, Testing Framework from CDC and Rockefeller Foundation)

https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-childcare-guidance.html

https://www.rockefellerfoundation.org/news/the-rockefeller-foundation-launches-new-testing-strategy-to-keep-u-s-economy-open/

Please provide an overview of goals and objectives of the practice. 

Goal(s) and objectives of practice.

Goal: Re-opening schools (K-12) and keeping them safe for in-person learning through COVID-19 Pandemic

Objectives:

1.     To provide free and accessible COVID-19 testing to schools

2.     To promptly detect cases of COVID-19 in schools especially among the vulnerable

3.     To rapidly respond to COVID-19 outbreak in schools

What did you do to achieve the goals and objectives?

Which steps were taken to implement the program?

Planning phase:

Stakeholders' engagement - school district management team, schoolteachers and nurses, parents' community, social media influencers, student community, CDC Foundation 

Laboratory assessment and selection – laboratory capable of a turn-key process with local presence, and 24-hour turnaround time (specimen collection to sharing of result to schools and parents

School assessment for existing COVID-19 infection prevention and control strategies

School testing pattern determination – frequency, date and ZIP  location cataloging

Parental consent – content and deployment strategy development 

Implementation phase:

Training of field staff – coordination, specimen collection among children, specimen transportation in optimal condition

 School nurses' training on student coordination for testing, resulting checking and sharing with parents

Development and distribution COVID-19 mitigation strategies information, education and communication (IEC) tools

Regular school visits for nasal sample collection, kit shipping, PCR testing and result sharing

Case investigation and contact tracing – 24-hour epi hot lines

Outbreak investigation and implementation of control strategies

Technical support for infection prevention with deployment of epidemiologists to schools to support nurses in implementing mitigation strategies.

What was the timeframe for the practice? Were other stakeholders involved? If so, what type and how?

Time frame: October 2021 -Date

The HHD School Testing Program involved active participation of relevant stakeholders to ensure a successful school COVID-19 testing/surveillance. The engaged stakeholders are classified  into internal (within HHD) and external  stakeholders (outside HHD)

Internal Stakeholders: include various units within HHD like the directorate of Laboratory services, call centers, school health units, outbreak units,

External stakeholders include Texas Education Agency, Department of State Health and Human Services, Centers for Disease Control and Prevention (CDC), school district management teams. Others include non-governmental agencies like Parents teachers' organizations, private laboratory, communities in which students reside and schools are located.

The stakeholders were engaged through all the phases of the program – planning and design, implementation and evaluation. The stakeholders were engaged through various media from individuals to groups, in-person, and virtual engagements.

What was the LHD's role in the planning and implementation of the process?

What did the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s).

The Local Health Department took leadership role in the planning and implementation of the School Testing Program by identifying and bringing together all relevant stakeholders (listed in section above) from the design phase through implementation and evaluation.

The health department also identified internal resources with school health experience, epidemic response expertise - epidemiology and laboratory, community engagement and communication experts. These various individuals had the one objective of ensuring a safe reopening of schools for in-person learning through the COVID-19 pandemic.

The HHD at the design phase elicited and addressed possible threats such as unconducive political terrain for COVID-19 testing at the State level, unfavorable school board perception of in-school testing, and possible parental refusal in the face of miscommunication and rumor mongering.

The HHD School Testing Program team consisted of physicians, nurses, epidemiologists, biostatisticians, laboratorians, community engagement leads, school liaisons to mention a few. These individuals served cross-cutting supportive roles to one another.

The School Health COVID-19 Chief Nurse Consultant engaged specifically for the program liaised with the ISDs and the school nurses. Being a highly experienced professional colleague, an effective engagement with the ISDs and the school nurses was achieved. Also, a team of highly motivated school liaisons engaged by HHD played a key role in initiating and maintaining collaboration with the schools and key community stakeholders e.g., wrap-around service providers who conducted health fairs, scheduled vaccine clinics and obtained parental consents for COVID-19 testing and uptake of vaccines.

The HHD School Testing Program conducted assessment of various laboratories and selected one with localized laboratory within the CoH capable of a turn-key process from digital consenting platform, field staff capacity to comb all schools based on the testing schedule, obtain and ship samples in optimal condition to the lab, and resulting of tests to school nurses and parents as indicated.

What steps were taken to ensure equitable, meaningful, and representative collaboration with target populations?

I.The HHD School Testing Program engaged with school principals to learn about the school community specific needs, and the most effective way to communicate with parent coummnity.

II.Regular meeting with school nurse managers to obtain their feedbacks and experienced challenges for quality improvemen

III.ISD management teams' visit to the testing laboratory for site seeing and quality reassurance.

IV. ISD ownership of the program and

V.Engagement with Parent Teacher Organization at school levels

VI.Providing in-school testing provided students and parents that depend on public transportations with easy/ convenient/assessable testing.

VII. Prioritized areas with high positivity rates and low vaccine up take for drive-thru testing. 

VIII. Provided in-school testing for a private school with special needs/fragile student population and staff.

IX.Testing promotions and consent forms were done in multiple languages.

Any start-up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.

The HHD through the CDC Reopening School Grants funded the following start-up activities:

ISDs in recruiting testing coordinators, testing supporting staff and purchase of office materials for testing with a sum of $1,300,000 allocated directly to the school districts.

Funds were provided for the purchase of antigen test kits through the Texas Department of State for Health and Human Services - ~$4,900,000 

PCR testing though contracted laboratory – (10,000,000)

Enter the local health department and community collaboration related to your practice.

The HHD School Testing Program had an active collaboration with some community stakeholders such as  .

Texas Education Agency (TEA) and Texas Department of State Health and Human Services (DSHS): - the HHD partnered with the TEA and DSHS to ensure all schools are carried along the testing program. The three agencies (state/local health and education) conducted joint webinars with school principals, nurses and administrators to provide guidelines on existing testing types, approaches reporting pathway.  

CDC foundation: With the supportive collaboration between HHD and CDCF, school liaisons were recruited and deployed to schools within underserved communities to provide assistance to school nurses and wrap around services.

School Principals: The school principals serve as the point of contact for each school with effective support from the school nurses

School Nurses/ISD Wrap around service providers: - The school nurses receive the daily test results from the screening testing conducted at their individual schools. They alongside the HHD Contact Tracing Team provide a follow up call to parents with child(ren) who test positive.

School district management teams: The HHD School Testing Program collaborated with the school district management teams to develop and agree on the Memorandum of Understanding that goes through the School District, Health Department and City Governing Council.  

Parents teachers' organizations: The Parents-Teachers Organization served as an effective platform to hear from parents – concerns and apprehension. The HHD epidemiologists attend the meeting fora to address the raised concerns and questions.

Private laboratory: With the engagement of a laboratory with local presence and capacity for a turn-key process from consent through sample collection, specimen shipping, testing and resulting, and a turnaround time of 24 hours, parents and teachers were assured of testing with efficient result-sharing.

What did you find out? To what extent were your objectives achieved? Please re-state your objectives if they were not included in your overview.

Objectives

 To provide free and accessible COVID-19 testing to schools- 100% Achieved

To promptly detect cases of COVID-19 in schools especially among the vulnerable- 80% Achieved

To rapidly respond to COVID-19 outbreak in schools- 100% Achieved

Findings:  Planning/Implementation (Quantitively and Qualitative)

Planning phase findings:

Community Themes and Strength Assessment

·       Parents eager to have children/scholars back in school

·       Negative psychosocial effect of isolated (at-home) learning

·       School structure not adequate for the ideal 6 feet apart sitting or movement arrangement recommended by the CDC

·       Plethora of misinformation, frightened teachers and parents

·       Non-availability of accessible and affordable COVID-19 testing for school populations - students and faculty

Local Public Health System Assessment

·       Inadequate manpower at Local Health Department to meet effective school health intervention

·       Not enough space, machines, and employee to deliver an expected turnkey and turnaround time

·       Schools were reporting self-identified COVID-19 cases to CTCMU that included an enormous number of suspected cases creating a huge workload for the CTCMU

·       No well-defined reporting system between the ISD and HHD

Community Health Status and Health Assessment

·       Lack of enough school nursing staff to do PCR testing,

·       Delay in reporting laboratory test result due to large volume

·       No in-school PCR Testing in all the ISD and schools (Inaccessible testing - parents traveling distances and using public transportation to get testing for their children and themselves)

·       School preference for different types of COVID-19 testing (PCR and/or Antigen)

·       School staff were frightened for personal infection, fear of the unknown

·       Knowledge gap on COVID-19 among staff

Forces of Change Assessment

·       State level political will not encouraging to COVID-19 mitigation strategy

·       Poor state level policies preventing effective school based COVID-19 Mitigation strategies

·       ISD Authority/District Specific Political and administrative will strong in some ISD and weak in others.

·        ISDs unwillingness to partner with local health department; ISDs agree to report testing but not testing

·       Religious private schools reluctancy to partner with government funding on COVID -19

·       Willingness to partner/collaborate

·       Funding for school testing made available by congress through approval of the Reopening School Grant

·       ISD wrap service providers had challenges with isolation, concern about getting parental consent and willingness to offer services on the pandemic /school health services

·       Available Parental Consent form though needed review to ensure clear communication of testing process, timing and expectations to parents

Implementation phase findings:

·       Four ISDs and 20 charter schools with a total of 443 public and 28 private schools were enrolled for testing - both PCR and/or antigen tests

·       Over 100,000 PCR tests were conducted, and 62,613 antigen tests supplied in

·       Sixteen emergency drive-through clinics were set up in response to school outbreaks with a total of 3,225 PCR tests conducted

·       Over the testing period, 104,430 PCR tests were conducted with 2,477 cases detected (2.4% COVID-19 cumulative positivity rate)

Did you evaluate your practice?

§  List any primary data sources, who collected the data, and how (if applicable).

Primary data collected:

1.     Number of COVID-19 PCR testing conducted - the PCR testing system was built on an online platform with varying degrees of accessibility determined by use for various individuals working from the various agencies school, health department, private laboratory etc. A tracking mechanism that determines daily number of samples obtained, shipped and tested enabled routine summarization of the COVID-19 PCR tests with results at individual level or school levels on a daily, weekly, monthly and quarterly. The staff analyst (biostatistician) on the Health Department's team is responsible for the collation of the data.

2.     Number of Antigen testing distributed for testing -  In collaboration with DSHS and TEA, a monthly summary of antigen tests supplied through vendors to schools is provided.

3.     Parent feedback on the Reopening School Testing Program. HHD developed an online questionnaire to obtain data on parental feedback and satisfaction as regards the testing program. Data obtained was analyzed and findings were incorporated into the current school year testing program.

                                      Primary Data Sources:

-Fulgent Genetics Laboratory

§  List any secondary data sources used (if applicable).

  I. ZIP Codes Transmission -Houston Electronic Disease Surveillance System (HEDSS).

 II.CoH demographic 2019 5-yr averages American Community Survey (ACS)

  III. Outbreak rates- Houston Electronic Disease Surveillance System (HEDSS).

  IV. COVID -19 Vaccination rates - ImmTrac2 (Texas Department of Health & Human Services)

 V. COVID-19 Community Vulnerability Index (CCVI) -Surgo Ventures

VI. ISD student/demographics population- Texas Education Agency (TEA)

List performance measures used and included process and outcome measures as appropriate.

Process measures

 I. Number of community engagement/stakeholders' meetings held,

 II. Number of ISDs involved in the project

 III. Number of Schools involved in the implementation

 IV. Number of trainings conducted

 V.Quantity of PCR testing kits supplied

 VI.Quantity of Antigen testing kits supplied

  VII.Quantity of IEC materials supplied

Outcome Measures.

 I.Number of staff trained (Laboratory and Nurses)

 II.Proportion of parental consents obtaine

  II Number of PCR test conduct

 IV. Number of COVID-19 antigen test conducted

V. Number of Positive PCR test resul

  VI.COVID-19 cumulative positivity rate

    VII. COVID-19 Outbreak investigations reported/carried out

    VIII. Number of schools provided with technical support for IPC guideline

§  List process and outcome measures related to health equity.

1a) Process: Use of vulnerability index to categorize the COVID-19 risk levels of schools

1b) Outcome: Outcome measures were: High risk, Medium risk and Low risk. Schools located in high-risk ZIP Codes had weekly deployment of field staff to conduct testing among all consented students and staff, while schools that fell within medium and low had biweekly testing schedule.  testing Measures: High Risk, Medium Risk and Low Risk

2a) Process: Monitoring of school positivity rate

2b) Outcome: Schools with increased positivity rate as observed from the surveillance screening are contacted to alert them of their status and review of existing IPC measures conducted to prevent further spread of infection

§  Describe how results were analyzed.

The primary data collected as an end-of-school year assessment enabled the review of the school communication platform and activation of other public health activity

Were any modifications made to the practice as a result of the data findings?

1)     80% of parents stated they enrolled their kids in the testing program as a preventive measure for COVID-19. That known, once the Emergency Use Authorization for the COVID-19 vaccine was received, the HHD vaccination team supported the schools in vaccinating the students and faculty with COVID-19 vaccines and other childhood vaccines.

2)     Part of the feedback received from parents included the preference to have information from school shared as text messages as different from the schools' blackboard usually used. This was shared with the school district and currently information goes out to parent communities through text messages

Lessons learned in relation to practice

i) The utilization of the Vulnerability Indices enabled the determination of at-most risk school population using ZIP codes, transmission rate, vaccination coverage and other social determinants of health such as employment, education etc. This enabled the Health Department to provide higher frequency of testing at schools that were most at-risk for outbreaks. The higher frequency of surveillance testing ensured surges were promptly detected and rapid response deployed, especially among the African American, Hispanic communities that were worse affected etc. This underscores the need for objective pre-implementation assessment of target population for public health intervention to ensure equity.

ii) Development of a well-guided implementation and evaluation plan for the school testing program enabled the close monitoring of expected outcomes, and getting on track when deviation are observed. This has been well transposed into the Mobilizing for Action Through Planning and Partnership (MAPP) template attached to the submission. Please find attached. 

 Lessons learned in relation to partner collaboration

i) In ensuring an effective and successful implementation, the HHD partnered with Texas Department of State Health Services (DSHS), Texas Education Agency (TEA) and various Independent School Districts (ISD) within the CoH jurisdiction. These collaborations ensured there were no duplication of efforts or overlaps, and all school districts understood the mechanism of request and report. The TEA, DSHS and HHD issued weekly updates to school administrators and coordinators of testing.

ii)Public Private Partnership: The HHD partnered with a commercial Laboratory with local presence which supported a turn-key approach that ensured test results were available and shared within 24hours

Lessons learned in relation to community engagement (if applicable).

1. Engagement of stakeholders from planning phase, implementation, and evaluation.         

We learnt that engaging stakeholders from the design phase of any public health program is very important in ensuring and sustaining commitment and goodwill. The school testing program based on contributions received from all stakeholders was widely acceptable, accessible and affordable. 

Lessons learned in relation to available funding or funding mechanisms (if applicable).

The funding which was from CDC Epidemiology and Laboratory Capacity for infectious diseases (ELC) project was strictly for COVID-19 intervention and did not allow intervention in other diseases like the other epidemic like RSV and flu which later broke out in the schools. However, there were secondary benefits from the funded testing program, that enabled students' linkage to care for other non-communicable disease screening and monitoring e.g., dental visits, eye screening etc.

Did you do a cost/benefit analysis? If so, please describe.

Schools in Texas districts receive state funding based in part on the Average Daily Attendance (ADA) numbers. Average Daily Attendance is a figure that indicates the average number of students that attend a particular school district in a school year. For example, if a student misses 9days out of the 180 days in a school calendar, the district loses 5% of the funding a student with a perfect attendance would generate. Through surveillance testing, cases of COVID-19 were detected early enough to prevent widespread among the students which would have led to many students missing school days, hence keeping as many students as possible in school. This kept the ADA of the schools in the districts high enough to ensure attracting of large enough state funding to the schools.

Is there sufficient stakeholder commitment to sustain the practice?

Describe sustainability plans.

COVID-19 has again demonstrated the relevance of intersectoral collaboration in Public Health, also with the entrenchment of the novel virus into our ecosystem, there is need to continually monitor for outbreaks of COVID-19 and respond rapidly cannot be over-emphasized. To ensure continuity of this practice the following sustainability activities and platforms were put in place.

1)     The established stakeholder's forum in Reopening Schools (Federal/State and Local Health Departments, State and Local Education Agencies) is committed to the sharing of data to monitor patterns and activate required response as needed.

2)     The forum meets monthly to review status and share new information to keep everyone updated on the COVID-19 school health program

3)      With support from the LHD, each school district is empowered with a response plan and communication channels to continue in the ongoing surveillance effort

4) Capacity building of school administrators and faculty (school principals, nurses, teachers, wrap-around service personnel etc. will ensure the early detection of an infectious disease outbreak and rapid coordination within the school environment

5)  With the expected ending of federal dollars July 2023 and possible exit of the private laboratory, the HHD laboratory is equipped to sustain the testing for COVID-19 in congregate settings and continue vaccination as needed