A little over a month ago, I delivered a webconference to the higher education community about safely bringing students back to campus. That presentation was the result of a massive effort of a large team of researchers. We reviewed hundreds of universities ‘repopulation’ plans, spoke with nearly 100 university leaders about those plans, and consulted leading public health experts and epidemiologists about the spread of disease in a university setting.
At that time, many colleges and universities were finalizing plans to bring reasonably large numbers of students back to campus. Our charge was to help them figure out how to do so safely. We built a rigorous framework for evaluating the plans across two major areas: containment (symptom monitoring, testing, contact tracing, and quarantine and isolation) and de-densification (reducing the number of people in densely populated areas of campus like classrooms and residence halls).
In the six weeks since then, the landscape has changed. A number of institutions have announced significant reductions in the number of students they plan to have return to campus. Here are the four major reasons why:
1. The spread of the disease is significantly worse today than it was a month ago and trending the wrong direction
On July 14, there were over 65,000 new confirmed COVID-19 cases, up from 18,800 new cases five weeks ago on June 9 (measuring against the same day of the week is important because test results vary by day of week). The 18,800 new cases on June 9 remains the fewest new cases reported on a Tuesday since March 24. June 9 also came after about 8 weeks of reasonably steady decline.
These numbers matter because universities are not bubbles (and even attempts at creating bubble-like environments—e.g., the MLS is Back Tournament—haven’t gone smoothly). Rather, they are integrated into communities. Faculty and staff live locally. Students live off-campus. Campus community members use local services like grocery stores and post offices and restaurants and banks. If there is widespread community transmission in your local community, it will be much harder to limit the spread of disease on campus.
2. Even with reduced numbers of students in and around campus, there have already been a number of concerning outbreaks
On July 3, the Seattle Times reported, in the space of five days, at least 117 positive cases were confirmed among a dozen fraternity houses at the University of Washington—with hundreds of tests still pending. At the time, there were roughly 1,000 students living in 25 fraternity houses at the university.
The existence of a denominator (out of 1,000 students) is unusual for media reports. It’s often hard to know exactly how many students are in and around campus. So, this particular anecdote provides a window into an overall infection rate for a specific population. In this instance, that infection rate is roughly 12%.
If the University of Washington’s 32,000 undergraduate students all return to campus in the fall, and 12% of them become infected over the course of an entire semester (a much longer timeframe than the 7 days took to produce these 117 infections), the result would be over 3,800 cases. By way of comparison, with no other cases among graduate students, faculty, or staff, that would make the University of Washington the largest “cluster” on the New York Times’ list of clusters. Currently, Marion Correctional Facility in Marion, OH, is atop the cluster charts with an outbreak of just under 2,500 cases.
The University of Washington is by no means the only campus experiencing student outbreaks. A number of athletic programs have experienced clusters upon their return that forced them to shut down for a period of time, including six cases at the University of Houston, 14 cases at Kansas State, and 47 cases at Clemson. Consequently, some smaller conferences have cancelled fall sports entirely (Centennial Conference, Ivy League).
3. The breakdown of COVID-19 testing infrastructure undermines efforts to contain the spread of disease on- and off-campus
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Recent news reports have indicated a significant breakdown of the infrastructure for molecular COVID-19 testing. The New York Times, LA Times, and PBS all ran feature stories within the past week about struggles with testing.
A press release from Quest Labs, one of the largest test labs in the US, noted that they could process results for tests in 24 hours for only the most urgent cases (e.g., hospitalized patients, pre-operative patients, and symptomatic healthcare professionals). For everyone else, the turnaround time now averages more than a week. The delays reflect not only the recent surge in cases, but unresolved supply chain challenges in testing infrastructure.
You might be wondering: Why is a long turnaround on test results a problem? The first and most obvious reason is that if you are planning on quarantining people who are awaiting test results, the delay significantly lengthens the time those people spend in quarantine. If students are placed in a separate quarantine facility, more beds will be needed. Even if students aren’t placed in quarantine facilities, compliance will be harder to achieve. Students will resist staying in their rooms and curtailing interpersonal interaction for a week or longer.
The deeper issue is that containment only works if you can trace the close contacts of infected individuals and ensure that they don’t infect others (also known as contact tracing). If you don’t begin tracing close contacts until seven days after someone who is tested is confirmed to be infected (when you learn the results of the test), those close contacts who were infected will already have had ample opportunity to pass the virus to others.
In short, a long turnaround time for processing tests and delivering results undermines the entire containment infrastructure. Given the high rate of asymptomatic or pre-symptomatic spread (people are most infectious slightly before exhibiting symptoms), quickly tracing close contacts and quarantining them until they can get test results themselves is essential for containing the spread of disease. Without the benefit of speed, this effort becomes nearly impossible.
4. If our ability to effectively contain infections is compromised, institutions will likely need to reduce the number of people who physically return to campus
The public health experts and epidemiologists we’ve spoken with agree that there’s a balance between containment (testing, tracing, and isolating infections) and de-densification. In other words, the more you can contain the spread of disease, the less you have to reduce the number of people in enclosed spaces.
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The emerging conditions I’ve outlined above mean that the balance between containment and de-densification many institutions were planning for in June is no longer feasible. Universities were planning robust testing protocols (we at EAB encouraged this!) for monitoring the spread of disease, followed by the rapid isolation of infected students. Some institutions have gone as far as planning to conduct widespread surveillance testing of asymptomatic students, the goals of which are to ensure that the disease is not spreading undetected on campus and to minimize the number of infections before the presence of disease is known.
But without quick access to results, the value of testing is severely curtailed. Institutions will be forced to isolate anyone displaying potential symptoms. Only those that can process tests on campus, through their own laboratories or medical centers, will be able to conduct widespread testing effectively. Consequently, we see a widening gap between institutions that can process tests in-house and those who are reliant on costly (and overwhelmed) commercial labs.
Collectively, these four trends have already precipitated a trickle of announcements walking back earlier plans for a full return to campus in place of a more remote fall semester. I expect more such announcements in the coming weeks. As much as everyone would like to get back to in-person instruction and dense campus life, the risks of such a return are mounting without any countervailing breakthrough in prevention measures.
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