Public health officials must provide guidance on operating schools safely during the COVID-19 pandemic. Using data from April-December 2021, we conducted a cost-effectiveness analysis to assess six screening strategies for schools using SARS-CoV-2 antigen and PCR tests and varying screening frequencies for 1000 individuals. We estimated secondary infections averted, quality-adjusted life years (QALYs), cost per QALY gained, and unnecessary school days missed per infection averted. We conducted sensitivity analyses for the more transmissible Omicron variant. Weekly antigen testing with PCR follow-up for positives was the most cost-effective option given moderate transmission, adding 0.035 QALYs at a cost of USD 320,000 per QALY gained in the base case (Reff = 1.1, prevalence = 0.2%). This strategy had the fewest needlessly missed school days (ten) per secondary infection averted. During widespread community transmission with Omicron (Reff = 1.5, prevalence = 5.8%), twice weekly antigen testing with PCR follow-up led to 2.02 QALYs gained compared to no test and cost the least (USD 187,300), with 0.5 needlessly missed schooldays per infection averted. In periods of moderate community transmission, weekly antigen testing with PCR follow up can help reduce transmission in schools with minimal unnecessary days of school missed. During widespread community transmission, twice weekly antigen screening with PCR confirmation is the most cost-effective and efficient strategy. Schools may benefit from resources to implement routine asymptomatic testing during surges; benefits decline as community transmission declines.
Keywords: COVID-19; cost effectiveness; screening.