Disclaimer: Information on this topic is rapidly evolving. We are not epidemiologists and we urge you to consult with the local public health experts when developing a testing plan.
Testing is the essential public health tool that identifies new outbreaks and allows us to quickly contain them. Perhaps no topic has been more frequently discussed, from the botched CDC tests in February, to current worries about the United States’ insufficient testing levels.
To safely bring students back to campus in any quantity this fall, colleges and universities will need to administer thousands of COVID-19 tests. Identifying an outbreak before it has spread widely likely requires testing not only symptomatic individuals, but also regularly testing asymptomatic people who could be spreading the virus. Although current testing levels may be sufficient to test symptomatic individuals in some locations, it’s unclear how much capacity there is for more systematic testing of asymptomatic individuals. This challenge is especially acute since to repopulate campus, universities would need to test not only students, but also faculty, staff, and anyone who regularly comes into contact with students—in short, anyone who is a part of the campus community.
Campuses are probably not as dangerous as prisons, slaughterhouses, or cruise ships, where some of the worst outbreaks to date have occurred. But the campus environment has several other characteristics that create a unique risk profile: students travel from across the country and world to attend, they are highly mobile during the semester, they interact with dozens of peers in classes, and they traditionally live in close quarters in residence halls.
Although most institutions acknowledge a need for testing in their reopening plans, few have provided concrete details about whom, how, and how often they plan to test. As leaders develop a plan for unprecedented COVID-19 testing in their communities, they must answer five key questions.
How many tests will my institution need?
Answering this question will require creating a sophisticated epidemiological model that is specific to your community. Nonetheless, we can glean a rough idea of how many tests a university might need to detect an outbreak during its initial phase from the “Return to Learn” pilot program, at the University of California, San Diego. Launched on May 11th, this program is available to the 5,000 students currently on campus. If successful, they plan to expand it to the entire campus community in the fall. Based on advanced epidemiological modeling and public health input, they claim,
- “By testing 60 to 90 percent of our campus population of students, faculty and staff for shedding of SARS-CoV-2 on a recurring [monthly] basis, our models suggest that we will have a greater than 90 percent chance of detecting viral spread at a time when less than 10 of the 60,000 members of our campus population are shedding virus, perhaps before these persons are symptomatic.”
- If UCSD implemented this level of testing during the fall semester, they would perform 126,000 to 189,000 tests per semester, or about 1,200 to 1,800 tests per day. That’s almost half the total number of tests currently performed in San Diego County.
- Use these formulas to ballpark the number of tests your institution would require during the fall semester to test at the same rate as the “Return to Learn” pilot:
- Low-end: (Size of campus community) x .14 x (number of weeks in your semester)
- High-end: (Size of campus community) x .21 x (number of weeks in your semester)
- Keep in mind that “Size of the campus community” includes students, faculty, staff, contractors, and anyone else who is regularly on campus. “Number of weeks in your semester” should also include time students spend on campus before instruction begins and after it concludes.
What kind of tests does my institution need?
Colleges will rely on tests that detect evidence of a present infection, called viral or infection tests. (Serological tests, which reveal evidence of past infection, are less useful in identifying active outbreaks.) There are three broad types of infection tests, all of which have benefits and drawbacks:
A medical professional uses a long swab to retrieve a viral sample from the back of the nose, which must be sent to a CLIA-certified lab, where technicians perform a reverse transcription polymerase chain reaction to amplify copies of viral genetic material and to compare it to SARS-CoV-2.
- Pros: Highly accurate. In addition, labs can process hundreds of samples at the same time.
- Cons: Although turn-around times have improved in recent weeks, these tests take a minimum of six hours to analyze in the lab, plus transit time of the sample to the lab. If widespread reopening leads to increased demand for limited lab capacity, wait-times could increase again. In addition, the test must be administered by a medical professional and it is generally invasive and unpleasant.
A nasal or throat swab is used to collect a sample that is analyzed with a special machine that can return results in under 45 minutes.
- Pros: Significantly shorter wait time for results, since the samples do not need to be sent to a lab.
- Cons: The machines can only process one sample at time, reducing the volume of tests that can be analyzed. In addition, some vendors have faced questions about high rates of false negatives.
Individuals use a sterile cotton swab to collect a sample from the shallow part of their own nasal cavity, which is then sent to a commercial lab for testing. (A saliva-based at-home test has also received Emergency Use Authorization from the FDA.)
- Pros: Minimally invasive and can be administered by the student.
- Cons: New to the market and, at time of writing, limited in supply.
Is it feasible for my institution to obtain and process that many tests?
Maybe. Supply of tests is currently on the rise. But as more countries reduce shutdowns and rely on testing to detect new outbreaks, demand for test kits will also increase globally. If your university has a large medical center and research lab capacity, you may be able to divert this capacity to testing. If not, your institution could be competing for scarce testing kits against other colleges, state governments, private corporations, sports leagues, and nation-states.
- If all US higher education institutions adopted the low-end of the “Return to Learn” pilot for their face-to-face students, about 12% of the current global weekly supply of 20 million tests would be consumed by US higher education alone. Even if global supply doubled or tripled, US higher education would still require a staggering portion of available tests.
- Supply chains for PCR tests remain weak. One major challenge is scaling the production of reagent, since this requires the creation of complex DNA components. Swabs are another bottle-neck and there are only two US-based swab manufacturers.
- Commercial and public lab capacity may not be sufficient to quickly process the tests needed by higher ed. Although lab capacity has improved, labs are reluctant to make large investments in processing equipment that would increase processing capacity. This excess capacity will be useless after the pandemic is over, and some labs are losing money and furloughing staff, because overall testing demand have declined as patients delay elective surgeries and routine bloodwork.
- Access to rapid diagnostic testing is even more limited. For example, local public health labs across the entire US are set to receive a total of only 5,500 machines from Abbott Labs, a major manufacturer of rapid testing devices. Since rapid diagnostic machines can only process one sample at a time, a university would need to acquire multiple machines to achieve the necessary volume. Expect supply to be tightly controlled, with hospitals and essential workers having priority.
How much will testing cost?
Recent estimates from EAB partners are around $500-800 per student, per semester. The current federal reimbursement rate for a test is $100, although actual cost can be lower or higher than that. Keep in mind, however, that these estimates assume that testing costs will remain constant through the fall. It’s possible that prices could go down, as more tests become available. It’s also possible that the cost of test kits could increase as demand rises during reopening, much as prices for some PPE have gone up by 1,000%.
How do I get the campus community to participate in testing?
After addressing the issues above, your institution will still need to convince students, faculty, and staff to be tested on a regular basis, even if they show no signs of infection.
- The EEOC has recently decided that employers can require employees to be tested for COVID-19 as a condition of entering a workspace for their shift, but on most campuses this will still require negotiations with faculty to agree on a testing protocol.
- It is a challenge to get all students on a campus to participate in any coordinated activity. The challenge of getting every student to swab her nostrils four times a semester will be even greater. While some students will appreciate the reassurance of continual testing, others will consider it an invasion of their privacy. Still others will judge the inconvenience of regular testing to not be worth the nebulous net good the community receives. Some will erroneously believe that young people are immune from severe COVID-19 cases altogether.
Colleges and universities are as integrated into their local economies as any other institution. It is unrealistic to believe that schools will be able to solve the testing problem on their campuses, while their local communities are still struggling to meet this challenge. Even if a university does manage to test at significantly higher rates than its local community, this might engender ill-will and raise questions about whether tests are being diverted from essential workers and health-care professionals. Some schools will have success partnering with local public health organizations. Other institutions with major medical centers or research facilities may be able to overcome the town-gown divide by providing testing to their local community. But the majority of US higher education institutions will be forced to compete for scarce testing supplies in a volatile marketplace.
We’re interested in hearing more about your plans for testing faculty, staff, and students. Please contact me at email@example.com if you are willing to talk about this topic.