Early in the tumultuous 2020-21 school year, Missouri officials made a big gamble: set aside roughly 1 million rapid covid tests for the state's K-12 schools in hopes 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 KHN 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 using just 32,300.
Missouri's effort provides a window into the complexities of covid testing at K-12 schools, even before the highly transmissible delta variant surged through. Delta's spread has mired communities in emotional fights about how to safely send children — who are mostly unvaccinated — back to classrooms, particularly in states like Missouri, 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's spread — potentially without a deep supply of test kits available.
Missouri educators described the testing that began last October as a blessing, for rooting out infected people and giving 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 the tests would deliver inaccurate results or that on-site testing of someone 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 students returned in November. It reserved its 120 tests for "emergency" situations.
"Schools that don't have a nurse on-site or any kind of medical staff on-site, it's just not as simple," said Robert Milner, principal of Hope Leadership Academy, a charter school in Kansas City that shipped dozens of tests back to the state. Milner said his school was able to mitigate covid with measures like temperature checks, a mask requirement, physical distancing and even getting rid of air dryers in bathrooms. Plus, "I have other options that I can send my families to" in the community for testing.
"We have no plans, nor is it our job, to administer this test to everyone," Lyndel Whittle, a public school superintendent, wrote in one district's application for tests. 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.
As the limits of remote learning became clear last year, officials pressed for a return to school. Gov. Mike Parson at one point said children would inevitably contract the virus at school, but "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, according to experts, despite the huge investment in rapid antigen tests. More recently, the Biden administration distributed $10 billion through the American Rescue Plan Act 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 Ginkgo Bioworks, in which the biotech company provides testing materials, training and staffing. As of mid-August, only 19 institutions had expressed interest, said Lisa Cox, state Department of Health and Senior Services spokesperson.
Unlike covid tests that use a polymerase chain reaction technique, which could take days to deliver results, rapid antigen tests return results within minutes. The trade-off: Studies have shown they are less accurate.
Still, for Halley Russell, president of the Missouri State Teachers Association and a high school teacher in Jackson, Missouri, 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]," 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, Missouri, said her 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 their 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 performed a few herself in the parking lot. State data as of early June shows the school received 200 tests and used 132. It did not require masking.
Many schools indicated they intended to test only staff members, applications obtained by KHN show. Missouri directed schools at first to use Abbott's rapid tests on symptomatic people, which further limited testing.
Arguably, some of the reasons limited testing occurred 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, according to state dashboard data that schools self-report, as of early June.
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, 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 nurse availability were also issues, he added.
"Many of our school districts don't have capacity to store the tests, to manage the testing," said Molly Ticknor, executive director of the Show-Me School-Based Health Alliance of Missouri, which focuses on access to health services at school.
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."
When the school year was over, Weldon, a registered nurse, said she shipped back "a lot" of unused tests, although she has since reordered to offer rapid testing to the public.
Cox, the DHSS spokesperson, said 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 are not required to report expired antigen test quantities to the state.
Mallory McGowin, spokesperson for Missouri's 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 received from the federal government. After accounting for tests K-12 schools didn't use, the state had shipped them 131,800 tests as of Aug. 17. "It quickly became clear," Cox said, "the tests we had pushed out were not being fully utilized."
When 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," she said, "to help with covid protocols."
School covid testing could "make a big difference," said Dr. Yvonne Maldonado, chief of Stanford University's pediatric infectious diseases division. However, the more important strategies to limit spread are masking, increased ventilation and getting more people vaccinated.
"Testing is more icing on the cake," she said.