Virginia is one of a growing number of states exploring testing as a way to combat COVID-19 in K-12 schools.
Dr. Laurie Forlano, a deputy commissioner for the Virginia Department of Health, said the agency is launching a pilot program to provide rapid antigen tests to schools across the state. VDH is rolling out the program with Abbott BinaxNOW tests — portable kits, roughly the size of a credit card, that provide results in around 15 minutes.
“We agree that testing can be a layer of prevention,” said Forlano, who oversees population health for the department. The concept of screening students and staff isn’t a new one, and some colleges and private K-12 schools have been testing since the fall. But it’s taken on a new importance since Virginia — like many states across the country — began encouraging local school divisions to reopen for in-person instruction.
As of March 22, only three of Virginia’s 132 school districts were operating fully remotely. The U.S. Centers for Disease Control and Prevention have also issued interim guidance for K-12 testing, which is largely mirrored by VDH in its own reopening guidelines for schools.
“I know there’s so much optimism and enthusiasm and work around vaccination,” Forlano said. “But the role of testing is still really important. Especially in schools, when younger children won’t have the opportunity to receive an approved vaccine probably until the fall or even the new year.”
The state is in the beginning stages of launching the pilot program, but Forlano said she aims to provide testing resources to every local school division that requests them. If a school expressed interest, VDH would send them free test kits and provide more information on the best practices for deploying them. The department also plans to launch a new website in the next week with a public testing toolkit and more information on the pilot program.
Forlano said VDH has been collaborating with other health departments in states that have launched similar programs. Both Maryland and North Carolina, for example, have been testing in schools with BinaxNOW kits. The concept is better known as “screening testing” — a way to identify potential cases even if students and staff aren’t showing symptoms.
The logistics of the program are complicated and often depend on the infrastructure and needs in individual communities or schools, according to Forlano. The end goal is stopping cases before they enter the building and potentially spread among students and staff. But there are multiple ways of deploying the tests. Some schools do pre-admission screening — testing students and staff before reopening the building. Others have launched weekly or even twice-a-week testing.
“I think what we’re envisioning is regular weekly testing,” Forlano said. But in large public schools, screening all students and staff might not be feasible, even with rapid results. What’s more likely is that schools will choose cohorts within their total population — teachers, for example, or their fourth grade class.
Regularly screening even a subset of the school is a way to identify undetected cases — roughly 40 to 50 percent of COVID-19 infections are asymptomatic, Forlano said — and gain a better understanding of whether transmission is occurring in the building.
“Obviously, if you’re not testing everyone, you’re not going to catch everything,” she said. “But you’ll catch a significant number, and that prevents spread throughout the school.”
In its guidance to local divisions, VDH stressed that screening testing is voluntary — even for students and staff in districts that adopt the program — and “may not be feasible in many communities.” Forlano said she’s heard concern from divisions that don’t have school nurses in every building. Others have schools spread across a large area, which can make distributing and managing the tests more of a challenge.
One potential solution is pooled testing. The method has been adopted for public schools across the state of Massachusetts and involves mixing multiple samples into one test batch. That batch is then tested with a PCR test, which delivers a positive or negative result for the entire sample.
A handful of colleges and private schools across Virginia have been offering the testing, including Shenandoah University. GENETWORx, a private laboratory near Richmond, also launched a pooled testing service in March in anticipation of growing demand from schools across the country.
“There are certain settings where pooled testing works really well, and schools are one of them,” said Steve Crossley, the company’s head of operations and strategy. Students in elementary and middle schools, especially, tend to spend the day in one homeroom class, which makes cohorting the tests easier. If one sample tests positive, those patients can be individually tested — or isolated or quarantined — without affecting the entire school’s operation.
GENETWORx offers the option of collecting a second sample at the time pooled tests are taken, which makes it easier to run individual tests if a batch comes back positive. But testing multiple samples at once is also cheaper than performing individual PCR tests.
“That’s kind of the beauty of the situation,” Crossley said. “So if you do see an outbreak, you have the ability to work with the school district to figure out next steps.”
National data and Virginia’s own outbreak dashboard indicate that large clusters of infections in schools are relatively rare. But cases do tend to rise with community infection rates. That makes pooled testing more challenging in areas with high transmission, where multiple batches would likely come back positive and require individual follow-up testing. Future trends are also hard to predict — roughly 80 percent of teachers across the state have been vaccinated, according to Gov. Ralph Northam, but it’s not clear how COVID-19 variants will affect transmission in schools as more students move back to the classroom.
Another potential drawback is that pooled testing can be expensive — even with fewer tests being run. “It’s easier for private schools because generally speaking, their budgets are a lot higher,” said Chtaura Jackson, an epidemiologist with the Richmond-Henrico Health District. Most also have fewer students and staff members, which makes it easier to test everyone on a weekly basis.
Only two to three private schools in her region have been offering pooled testing, and some have shifted from testing their entire populations to specifically focusing on student athletes. It’s reflective of the higher risk that sports pose when it comes to COVID-19 transmission.
From October to December 2020, school athletics accounted for about 10 percent of all school-related outbreaks, according to Forlano. But in January, as cases spiked across the commonwealth, that number jumped to roughly 50 percent. The percentage declined to 43 percent in March, and numbers have still been relatively small.
Right now, the state is offering free rapid antigen tests because it has a large supply of them. Dr. Brooke Rossheim, a public health physician specialist on the state’s COVID-19 testing team, said Virginia received 2.2 million BinaxNOW cards through an allotment from the U.S. Department of Health and Human Services.
But the CDC recently announced additional grant funding to states through the American Rescue Plan with a specific emphasis on supporting K-12 schools. Forlano said Virginia is eligible for up to $250 million, and the state is hoping to quickly leverage the funding to support school testing programs.
VDH plans to run its pilot through June 30 — or until supplies last — but supplement a long-term program with federal funds. Those resources would allow the agency to expand the type of tests it’s offering to schools.
“Our ability to explore different technologies and methodologies is wider now,” Forlano said. “So we would consider adding pooled testing to the menu of options that a school could avail itself of.”
She emphasized that it’s not a replacement for other mitigation measures, such as masking and social distancing. But there’s national hope that testing could be the key to keeping schools open until both adults and children can access vaccines.