The US has reported over 30 million COVID-19 cases and 500,000 deaths since the start of the pandemic.¹ With COVID-19 vaccination underway, communities are implementing measures to facilitate a safe return to normalcy. However, outbreaks of COVID-19 cases, variable vaccination acceptance, and uncertainty associated with variant strains indicate that COVID-19 transmission risks remain and provide reasons for ongoing surveillance. For example, 20% of individuals in the US report that they will “definitely not get the vaccine” or will do so “only if required,” and another 30% report that they will “wait and see” on getting a vaccine.²

COVID-19 diagnostic testing can help limit transmission and mitigate outbreaks.³ According to leaders at the National Institutes of Health, COVID-19 testing is key to returning to normalcy as testing can identify those in need of care and interrupt the spread among both symptomatic and non-symptomatic individuals.⁴ There are 2 basic types of COVID-19 diagnostic tests: antigen tests and molecular tests. Antigen tests—sometimes called rapid diagnostic tests—detect specific proteins on the surface of the virus and often provide results in an hour or less. Molecular tests, including nucleic acid amplification tests such as polymerase chain reaction tests, amplify and detect the virus’ genetic material. These tests are usually run in a laboratory facility and can return results in 24–72 hours. Antigen tests have been reported to be more likely to yield false-negative results relative to molecular tests, meaning that COVID-19 cases may be missed. Negative results are typically confirmed with a molecular test or further serial antigen testing across 1–3 days.⁵

As the US moves to ensure a safe return to schools, workplaces, and other community settings, COVID-19 diagnostic testing can be an effective tool in helping prevent transmission and control the potential spread of the virus. Tradeoffs between timing, resources, risk of transmission, and accuracy of results must be weighed. In some settings where transmission risk is high and immunization is not available or vaccine uptake is low, the need for highly sensitive and accurate testing will be critical considerations. The military and schools are important examples of populations that may benefit from strong testing policies given the risks and consequences of transmission.

Military: Accurate Testing to Maintain Operational Readiness

Over 183,000 military services members have tested positive for COVID-19 since the start of the pandemic, and transmission continues to be a significant risk due to the nature of the living and working environment.⁶ Additionally, medical infrastructure supporting deployments is built for the needs of battlefield injuries rather than for respiratory support and large volumes of acutely ill patients.⁷ A study modeling the implications of COVID-19 transmission aboard a deployed 5,000-sailor warship found that even with lower-end assumptions of transmission, resource implications could be significant and may include shortages of hospital beds or mechanical ventilators.⁸

Although vaccinating soldiers has been a priority, COVID-19 transmission risks among military personnel will remain, given variability in vaccination uptake. As many as one-third of vaccine-eligible service members have refused the vaccine, and close to 40% of Marines have declined the vaccine.^9,10 Moreover, service members may be deployed to parts of the world with lower vaccination rates or active outbreaks and may therefore be at increased risk for exposure to COVID-19, including regional variants.

With such significant impacts on day-to-day operations and mission readiness, along with threats to personnel health and safety, some, including Dr. Nelson Michael, an infectious disease researcher and physician at the Walter Reed Army Institute of Research, have called for the use of more sensitive molecular testing to support health and safety in the military.¹¹

Education: Accurate Testing to Keep Schools Open

Beginning in March 2020, many states ordered or recommended closing K–12 schools as a broad strategy to slow the transmission of COVID-19. Prolonged school closures have impacted the educational and economic landscape and will likely have lasting effects on students, teachers, and parents. Examples of these impacts include the loss of in-person learning, which has disproportionately affected students with learning disabilities and those from disadvantaged backgrounds, loss of social services provided by schools (e.g., meals and health services), and loss of socio-emotional and motivational development.^12,13 A survey also reported that 13% of parents had to reduce their working hours or leave work entirely to compensate for the loss of childcare availability due to school and childcare closures.¹⁴

Across the country, many states are reopening their schools; however, recent surges in cases, such as the more than two-fold increase in cases among children under 19 reported by the Michigan Department of Health and Human Services in February 2021, underscore the need for continued COVID-19 testing.¹⁵ Evidence strongly suggests regular testing is effective in reducing the risk of transmission within schools, as 1 study found weekly testing of all students, teachers, and staff can reduce in-school infections by an estimated 50%.¹⁶

Developing strong testing protocols built on the accuracy of molecular testing can help bring students back into classrooms safely and reduce future absences. In January 2021, Massachusetts made weekly COVID-19 pooled testing available to public schools. Pooled testing, an approach in which several individual samples are mixed and tested with a molecular diagnostic test, increased the number of individuals that could be tested and was used as a screening method. In March 2021, data collected across the commonwealth found low positivity rates (less than 1%) among students and staff, suggesting that a pooled testing approach is effective in preventing the transmission of COVID-19 in schools.¹⁷

Conclusion

Accurate COVID-19 diagnostic testing can help support reopening plans across the country. Vaccine distribution will continue to reduce the risks of COVID-19 transmission, but the risks of transmission will continue, given variability in vaccine uptake and the potential for emerging COVID-19 variants. Both the military and schools provide examples of populations where the risks and consequences of COVID-19 transmission are high. With close to one-third of military service members refusing the COVID-19 vaccine and vaccine trials for children under the age of 12 just beginning,¹⁸ testing strategies that combine both molecular and serial antigen testing can support the return to normalcy, ensure safety, and minimize disruption to the military and schools.

Funding for this research was provided by Hologic, Inc. Avalere Health retained full editorial control.

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Notes

1. Centers for Disease Control and Prevention. COVID Data Tracker (April 2021).
2. Kaiser Family Foundation. COVID-19 Vaccine Monitor (April 2021).
3. Centers for Disease Control and Prevention. Overview of Testing for SARS-CoV-2 (COVID-19).
4. National Institutes of Health. Why COVID-19 Testing Is the Key to Getting Back to Normal (September 2020).
5. US Food & Drug Administration. Coronavirus (COVID-19) Update: FDA Continues to Advance Over-the Counter and Other Screening Test Development (March 2021).
6. Department of Defense. Coronavirus: DOD Response.
7. Dutton, L. K., Rhee, P . C., Shin, A. Y., et al. Combating an Invisible Enemy: The American Military Response to Global Pandemics. Military Medical Research 8.1 (2021): 8.
8. Vicente, D., Maves, R., Elster, E., & Shwayhat, A. US Navy’s Response to a Shipboard Coronavirus Outbreak: Considerations for a Medical Management Plan at Sea. Military Medicine 186.1–2 (2021): 23–26. Available here
9. Myers, M. About a Third of Troops Have Turned Down the COVID-19 Vaccine. Military Times (February 17, 2021).
10. Liebermann, O., Kauffman, E., Cole, D. Nearly 40% of Marines Have Declined COVID-19 Vaccines. CNN Politics (April 20, 2021).
11. Michael N. L. SARS-CoV-2 in the US Military: Lessons for Civil Society. New England Journal of Medicine 383.25 (2020): 2472–2473.
12. Hanusek, E., and Woessmann, L. The Economic Impacts of Learning Losses. Better Policies for Better Lives (September 2020).
13. The Rockefeller Foundation & Health Catalysts Group. K–12 National Testing Action Program: Connecting Schools with the Nation’s Leading Testing Companies to Safely Reopen (2020).
14. The Johns Hopkins Bloomberg School of Public Health. Risk Assessment and Testing Protocols for Reducing SARS-CoV-2 Transmission in K–12 Schools (October 2020).
15. Bayer M. COVID-19 Cases Spike in Michigan, Fueled by Infections Among Kids. CBS News.
16. The Rockefeller Foundation & Health Catalysts Group. K–12 National Testing Action Program: Connecting Schools with the Nation’s Leading Testing Companies to Safely Reopen (2020).
17. Mass.gov. Baker–Polito Administration’s First in the Nation COVID-19 Pooled Testing Initiative Finds 0.7% Positivity Rate in Schools Throughout Commonwealth (2021).
18. Pfizer. Pfizer-Biontech Announce Positive Topline Results of Pivotal COVID-19 Vaccine Study in Adolescents (March 31, 2021).