A major challenge of the COVID-19 pandemic has and continues to be our ability to test for the presence of SARS-CoV-2 effectively, efficiently, and economically in both symptomatic and asymptomatic individuals. As tests become more available to camps this season, it is more important than ever to understand the role and limitations of testing in the camp environment.
What Tests to Use
Two major types of tests are available for camps this season: antigen (commonly known as “rapid”) and molecular (most commonly “RT-PCR”). Testing results are typically indicative of exposures three to five days prior to the testing day. Antigen tests can be done in the camp setting, while molecular tests are more commonly done in a laboratory. Antigen tests have quick results; however, post-market studies of rapid antigen tests have shown variable testing characteristics. Antigen test are generally less sensitive than molecular tests for detecting the presence of COVID-19, and the clinical performance of these tests largely depends on the circumstances in which they are used. High numbers of false negatives in both types of tests limit the ability to interpret anything but momentary infectious status.
Molecular tests are considered the gold standard of testing because they are very good at picking up an infection if it is present. However, time from collection to results is highly variable, ranging from two to seven days depending on the laboratory. False negative results for molecular tests can occur due to improperly collected samples, exposures after testing, or testing too soon after exposure.
Testing is simply another layer in our public health protection; we cannot test into certainty that COVID-19 is not present in our camp attendees. Camp health professionals should understand test performance characteristics in the current COVID-19 climate and recognize potentially false negative or false positive test results to guide additional confirmatory testing. Additionally, camps performing tests on-site must apply for a Clinical Laboratory Improvement Amendment (CLIA) Certificate of Waiver to perform FDA-waived tests in the nonlaboratory setting.
For additional information:
- Centers for Medicare and Medicaid Services’ How to Obtain a CLIA Waiver
- Centers for Disease Control and Prevention’s Overview of Testing for SARS-CoV-2 and Testing Strategies for SARS-CoV-2
- Food & Drug Administration’s FAQs on Testing for SARS-CoV-2
- American Camp Association’s Field Guide for Camps (Table 13.1 lists the factors related to using molecular, antigen, and antibody testing for camp attendees)
Noses and Spit: What Sample to Use
COVID-19 tests are performed on collected specimens including deep nasal, mid or anterior nasal, and mouth or saliva. Each specimen type has benefits and limitations. For example, a saliva specimen tends to function as well as a nasal test but may require not eating for an hour before and being well hydrated. Many people find the deep nasal specimen collection quite uncomfortable, but anterior nasal testing requires multiple “sweeps” to obtain enough sample. Whatever sample is used, the collection of the sample should be monitored for quality, because a poor sample will yield an uninterpretable result.
Who Pays for Testing
Payment for COVID-19 testing depends on the situation for testing (diagnostic vs. screening), testing availability and type, federal and state regulations, and individual insurer policies, among other factors. Camps should investigate if the expense of testing can be shouldered by attendee insurers, be a shared expense between families and camp, or if the camp must shoulder the full cost of testing alone.
Day Camp Considerations
The day camp environment is more likely to reflect local rates of COVID-19, and, as such, one-time screening testing may have a lesser role than surveillance and mitigation testing. Like day schools or workplaces, all attendees commute and return home each day, making testing representative only of the current status at the time the test is carried out. Surveillance testing is increasingly being used in these settings, but frequency of testing (e.g., weekly, biweekly, or monthly) depends on the characteristics of the camp (i.e., size, proximity of people, duration) and local COVID-19 rates. See the ACA Field Guide for Camps for more information.
Testing Strategies for Overnight Camps
Testing scenarios for camps should follow state and local public health guidelines. Potential testing strategies are discussed in following sections.
Testing prior to camp is considered “prescreening” testing and is strongly recommended for overnight camps. Tests must be scheduled with sufficient turnaround time to allow for results to be assessed prior to travel (note that some test results can be delayed by several days). Results should be reported to the camp health center or administration before the first day of camp to allow for confirmation of test type and negative result. When available and results can be obtained quickly (i.e., within less than 72 hours), RT-PCR tests are considered the most sensitive for identifying cases early in infection.
- Good: Campers and staff are tested at home within five to seven days of travel to residential camp. Low-risk behaviors are advised for 10–14 days prior to camp.
- Better: Campers and staff are tested within 72 hours of arrival at camp. Low-risk behaviors are advised for 10–14 days prior to camp.
Note: Some states require a post-travel quarantine period based on several factors, including the community transmission rate of the traveler’s home area.
Arrival and Post-Arrival Testing
Testing at camp is recommended for overnight camps. Test choice and schedule should be made in conjunction with your camp health team and state health regulations (suggested potential options follow). Camps may be able to obtain testing supplies and laboratory relationships that make on-site rapid antigen testing and/or RT-PCR collection feasible. The characteristics of camp (e.g., duration, migration in and out of camp, method of travel to camp, etc.) will determine the cadence of post-arrival testing. Camps shorter than five to seven days may decide against further testing after arrival.
If camps develop capacities for testing, the following best practices should be considered:
- Good: Overnight camps perform a rapid antigen test upon camper and staff arrival.
- Better: Overnight camps perform a rapid antigen test upon camper and staff arrival and PCR testing at an interval after arrival.
- Testing prior to Day 3 will miss exposures on travel days but would identify early any positives that were not detected from the rapid antigen test.
- Testing Days 3–5 may detect travel day exposures but give a number of false negative tests from testing too soon after exposure.
- Testing Days 5–8 will detect travel day exposures and capture the vast majority of individuals who would turn positive from pre-camp exposures.
It should be noted that all campers and staff should wear face coverings while waiting to be tested, keep physically distanced from all individuals outside their cohort, and adhere to the strictest and most diligent nonpharmaceutical interventions until testing status can be obtained.
Testing Vaccinated Individuals
Guidelines for testing vaccinated individuals are being developed every day. At the time of writing, the Centers for Disease Control and Prevention state that vaccinated individuals still need to test if they have symptoms consistent with COVID-19. Vaccinated individuals do not need to be tested if they are exposed to somebody who has known COVID-19 (unless they are living in congregate settings). Studies have shown that fully vaccinated individuals can be PCR positive for COVID-19 but without symptoms. Without coughing and sneezing, we would suspect that transmission from vaccinated individuals would be exceedingly rare, however, we are still waiting for data to support this. Variants additionally pose a potential for reinfection in vaccinated individuals. Until further and more specific guidance, vaccinated individuals at camp should be included in testing.
In summary, testing is one important tool in our arsenal of public health interventions for a successful and healthy camp summer. Camp directors should work in conjunction with public health and healthcare professionals to determine the best testing plan for your camp. Communicable diseases like COVID-19 will continue to be a challenge for camps and other community-based experiences, and understanding the role of testing will help us broaden our prevention efforts and promote a healthy camp environment.
Author’s Note: The information shared in this article represents knowledge at the time of creation and, with rapidly changing guidelines and science, should be interpreted in this context. The opinions expressed here are my own and not necessarily those of state and federal authorities and other regulating bodies. This article is intended for educational purposes and does not replace independent professional judgment.
Laura Blaisdell, MD/MPH, FAAP, is the medical director of Camp Winnebago in Maine, and the 2021 recipient of the Eleanor P. Eells Award for Excellence in Research in Practice.
Photo courtesy of Elbow Lane Day Camp, Warrington, PA.