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      COVID-19 Testing and Case Rates and Social Contact Among Residential College Students in Connecticut During the 2020-2021 Academic Year

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          Key Points

          Question

          What is the association between COVID-19 testing and case rates on residential college campuses?

          Findings

          In this cohort study of 18 Connecticut colleges and universities, infrequent COVID-19 testing of residential students was not associated with decreased transmission, whereas testing of residential students twice per week was associated with decreased transmission during the 2020-2021 academic year.

          Meaning

          Findings suggest that twice-weekly COVID-19 testing of residential students may serve as an effective infection mitigation strategy at colleges and universities.

          Abstract

          Importance

          During the 2020-2021 academic year, many institutions of higher education reopened to residential students while pursuing strategies to mitigate the risk of SARS-CoV-2 transmission on campus. Reopening guidance emphasized polymerase chain reaction or antigen testing for residential students and social distancing measures to reduce the frequency of close interpersonal contact, and Connecticut colleges and universities used a variety of approaches to reopen campuses to residential students.

          Objective

          To characterize institutional reopening strategies and COVID-19 outcomes in 18 residential college and university campuses across Connecticut.

          Design, Setting, and Participants

          This retrospective cohort study used data on COVID-19 testing and cases and social contact from 18 college and university campuses in Connecticut that had residential students during the 2020-2021 academic year.

          Exposures

          Tests for COVID-19 performed per week per residential student.

          Main Outcomes and Measures

          Cases per week per residential student and mean (95% CI) social contact per week per residential student.

          Results

          Between 235 and 4603 residential students attended the fall semester across each of 18 institutions of higher education in Connecticut, with fewer residential students at most institutions during the spring semester. In census block groups containing residence halls, the fall student move-in resulted in a 475% (95% CI, 373%-606%) increase in mean contact, and the spring move-in resulted in a 561% (95% CI, 441%-713%) increase in mean contact compared with the 7 weeks prior to move-in. The association between test frequency and case rate per residential student was complex; institutions that tested students infrequently detected few cases but failed to blunt transmission, whereas institutions that tested students more frequently detected more cases and prevented further spread. In fall 2020, each additional test per student per week was associated with a decrease of 0.0014 cases per student per week (95% CI, –0.0028 to –0.00001).

          Conclusions and Relevance

          The findings of this cohort study suggest that, in the era of available vaccinations and highly transmissible SARS-CoV-2 variants, colleges and universities should continue to test residential students and use mitigation strategies to control on-campus COVID-19 cases.

          Abstract

          This cohort study assesses the associations between COVID-19 testing and case rates and social contact to characterize reopening strategies for residential students at college and university campuses in Connecticut.

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          Most cited references34

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          Outbreak of SARS-CoV-2 Infections, Including COVID-19 Vaccine Breakthrough Infections, Associated with Large Public Gatherings — Barnstable County, Massachusetts, July 2021

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            Assessment of SARS-CoV-2 Screening Strategies to Permit the Safe Reopening of College Campuses in the United States

            Key Points Question What screening and isolation programs for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will keep students at US residential colleges safe and permit the reopening of campuses? Findings This analytic modeling study of a hypothetical cohort of 4990 college-age students without SARS-CoV-2 infection and 10 students with undetected asymptomatic cases of SARS-CoV-2 infection suggested that frequent screening (every 2 days) of all students with a low-sensitivity, high-specificity test might be required to control outbreaks with manageable isolation dormitory utilization at a justifiable cost. Meaning In this modeling study, symptom-based screening alone was not sufficient to contain an outbreak, and the safe reopening of campuses in fall 2020 may require screening every 2 days, uncompromising vigilance, and continuous attention to good prevention practices.
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              Multiple COVID-19 Clusters on a University Campus — North Carolina, August 2020

              On September 29, 2020, this report was posted online as an MMWR Early Release. Preventing transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), in institutes of higher education presents a unique set of challenges because of the presence of congregate living settings and difficulty limiting socialization and group gatherings. Before August 2020, minimal data were available regarding COVID-19 outbreaks in these settings. On August 3, 2020, university A in North Carolina broadly opened campus for the first time since transitioning to primarily remote learning in March. Consistent with CDC guidance at that time ( 1 , 2 ), steps were taken to prevent the spread of SARS-CoV-2 on campus. During August 3–25, 670 laboratory-confirmed cases of COVID-19 were identified; 96% were among patients aged <22 years. Eighteen clusters of five or more epidemiologically linked cases within 14 days of one another were reported; 30% of cases were linked to a cluster. Student gatherings and congregate living settings, both on and off campus, likely contributed to the rapid spread of COVID-19 within the university community. On August 19, all university A classes transitioned to online, and additional mitigation efforts were implemented. At this point, 334 university A–associated COVID-19 cases had been reported to the local health department. The rapid increase in cases within 2 weeks of opening campus suggests that robust measures are needed to reduce transmission at institutes of higher education, including efforts to increase consistent use of masks, reduce the density of on-campus housing, increase testing for SARS-CoV-2, and discourage student gatherings. University A students returned to residence halls during August 3–9, 2020, and in-person classes began on August 10. Mitigation steps taken to prevent the spread of SARS-CoV-2 on campus included scheduling move-in appointments across a 1-week period, decreasing classroom density to facilitate physical distancing, and reducing maximum dining hall capacity and increasing takeout options. Students were required to sign an acknowledgment of community standards and university guidelines recommending daily symptom checks, use of masks in all indoor common spaces and classrooms, physical distancing of ≥6 feet in indoor and outdoor settings, and limitations on group gatherings consistent with local guidelines (groups of no more than 10 persons indoors and 25 outdoors). Approximately 95% of students signed the acknowledgment; however, data on adherence to these important mitigation strategies were not available. Reentry testing for COVID-19 and quarantine before or after arrival on campus were not used ( 1 ). Except for two dormitories reserved for isolation and quarantine, residence halls opened at 60%–85% capacity, with most students in double rooms. Those at increased risk for severe illness from COVID-19, according to CDC guidance ( 3 ), had the option to request a single room. Undergraduate enrollment in university A for the fall semester was 19,690 students. Approximately 5,800 (29%) of these undergraduate students resided on campus as of August 10. In 2019, 83% of undergraduate students were North Carolina residents. By August 25, 670 laboratory-confirmed cases of COVID-19 with a specimen collection date for SARS-CoV-2 testing of August 3 or later had been identified among students, faculty, and staff members at university A (Figure). Cases were identified by the student health clinic (by self-report or through testing at the student health clinic or the university hospital testing center) or linked to a university cluster by the local health department. Initial information was collected by the university at the time of testing; the university also implemented contact tracing, isolation, and quarantine. Additional investigation of cases was conducted by the local health department for students who were tested off campus. Cases were classified according to the Council of State and Territorial Epidemiologists COVID-19 2020 Interim Case Definition ( 4 ). An additional 120 potential cases identified by the student health clinic had insufficient information to meet criteria for confirmed or probable COVID-19 and were not included in the analysis. Information on cases reported only to the university employee occupational health clinic, which is separate from the student health clinic, was not available for review at the time of analysis. FIGURE Confirmed COVID-19 cases among university A students, faculty, and staff members (N = 670), by earliest illness identification date — North Carolina, August 2020 Abbreviation: COVID-19 = coronavirus disease 2019. The figure is a histogram, an epidemiologic curve showing 670 confirmed COVID-19 cases among university A students, faculty, and staff members, by earliest illness identification date, in North Carolina during August 2020. Among 670 confirmed cases with specimen collection dates during August 3–25 for SARS-CoV-2 testing, median patient age was 19 years (range = 17–50 years), and 293 (47%) cases occurred in males (information on gender was missing for 47 [7%] patients). Information on school affiliation (e.g., undergraduate versus graduate/professional student, faculty, or staff member) was not consistently recorded; however, considering patient age <22 years as an indicator of undergraduate status, 643 (96%) cases were estimated to have occurred in undergraduate students; among these students, 230 (36%) resided on campus, and at least 51 (8%) were members of a fraternity or sorority and 51 (8%) were student athletes. For the remainder, place of residence, including if living at home or in shared apartments, was not readily available. As of August 25, no COVID-19 patients were hospitalized or had died, and no cases of multisystem inflammatory syndrome in children or adults were reported. One student was kept for extended observation in a hospital emergency department. Information on other clinical manifestations, such as myocarditis, was not available. Clusters were defined as the occurrence of five or more epidemiologically linked cases (e.g., common residence, sports team, or fraternal organization membership) within 14 days of one another (by earliest date of illness identification). During August 3–25, 18 clusters at university A were identified, eight in residence halls, five among students with membership in a fraternity or sorority, one in off-campus apartments, and four among athletic teams. Overall, 201 (30%) cases were linked to a cluster. Clusters ranged in size from five to 106 patients (median = five), with the largest cluster associated with a university-affiliated apartment complex. On August 19, when 334 (50%) university A–associated cases had been reported to the local health department, all university A classes transitioned to online, and efforts to reduce the density of on-campus housing commenced. Testing for SARS-CoV-2 was recommended for all persons living in residence halls with case clusters and was offered to all students at the student health clinic and the university hospital testing center. Students living in on-campus residence halls were required to return home unless they applied for and received a hardship waiver indicating they could remain on campus. All students returning home were instructed to self-quarantine for 14 days following departure from campus. Off-campus testing sites were set up both to meet community needs and target off-campus student housing complexes with multiple cases. Discussion Rapid increases in COVID-19 cases occurred within 2 weeks of opening university A to students. Based on preliminary case investigations, student gatherings and congregate living settings, both on and off campus, likely contributed to the rapid spread of COVID-19 on campus. This suggests the need for robust and enhanced implementation of mitigation efforts and the need for additional mitigation measures specific to this setting. The findings in this report are subject at least five limitations. First, the number of reported cases at university A is likely an underestimate. For example, some cases were reported to students’ home jurisdictions, some students did not identify themselves as students to the county health department, some students did not report to the student health clinic, and not all students were tested. Second, the number of students possibly infected through affiliation with a fraternity or sorority is likely underestimated. Some students might not have disclosed their fraternity or sorority membership, and other students (who were not members of fraternities or sororities) might have participated in unofficial rush events and parties. Third, limited information was available on housing arrangements for students not identified to live on campus, as well as information about the extent of social gatherings and adherence to masking and other important mitigation efforts. Fourth, cases had limited clinical follow-up; thus, the extent of longer-term clinical complications is not known. Finally, because information available on cases in faculty and staff members was limited, the contribution of faculty or staff members to COVID-19 spread on campus cannot be estimated. The rapid increase in COVID-19 cases among college-aged persons at university A underscores the urgent need to implement comprehensive mitigation strategies ( 5 , 6 ). In addition to enforcement of mask requirements, measures needed to reduce transmission in college and university settings might include efforts to reduce the density of on-campus housing, increase testing for SARS-CoV-2, and discourage student gatherings. Emerging findings from ongoing monitoring and evaluation efforts at universities and colleges in North Carolina and nationwide are helping to update best practices, including optimal testing strategies, for preventing SARS-CoV-2 transmission on campus and in the adjacent communities. Summary What is already known about this topic? Before August 2020, minimal data were available about outbreaks and disease transmission in institutes of higher education within the United States. What is added by this report? A North Carolina university experienced a rapid increase in COVID-19 cases and clusters within 2 weeks of opening the campus to students. Student gatherings and congregate living settings, both on and off campus, likely contributed to the rapid spread of COVID-19 in this setting. What are the implications for public health practice? Enhanced measures are needed to reduce transmission at institutes of higher education and could include reducing on-campus housing density, ensuring adherence to masking and other mitigation strategies, increasing testing for SARS-CoV-2, and discouraging student gatherings.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                23 December 2021
                December 2021
                23 December 2021
                : 4
                : 12
                : e2140602
                Affiliations
                [1 ]Yale School of Public Health, New Haven, Connecticut
                [2 ]Connecticut Department of Public Health, Hartford
                Author notes
                Article Information
                Accepted for Publication: October 30, 2021.
                Published: December 23, 2021. doi:10.1001/jamanetworkopen.2021.40602
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Schultes O et al. JAMA Network Open.
                Corresponding Author: Forrest W. Crawford, PhD, Yale School of Public Health, 60 College St, New Haven, CT 06510 ( forrest.crawford@ 123456yale.edu ).
                Author Contributions: Dr Crawford had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Schultes, Clarke, Cartter, Crawford.
                Acquisition, analysis, or interpretation of data: Schultes, Clarke, Paltiel, Sosa, Crawford.
                Drafting of the manuscript: Schultes, Clarke, Crawford.
                Critical revision of the manuscript for important intellectual content: Schultes, Paltiel, Cartter, Sosa, Crawford.
                Statistical analysis: Schultes, Crawford.
                Obtained funding: Crawford.
                Administrative, technical, or material support: Schultes, Clarke, Sosa, Crawford.
                Supervision: Cartter, Crawford.
                Conflict of Interest Disclosures: Dr Sosa reported grants from the Centers for Disease Control and Prevention during the conduct of the study. Dr Crawford reported receiving personal fees from Whitespace Ltd, consulting fees from Whitespace Ltd during the conduct of the study, and grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.
                Funding/Support: This work was funded by Cooperative Agreement 6NU50CK000524-01 from the Centers for Disease Control and Prevention, funds from the COVID-19 Paycheck Protection Program and Health Care Enhancement Act, grant 1DP2HD091799-01 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Pershing Square Foundation.
                Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Additional Contributions: Jacqueline Barbieri, MA, Jared Campbell, MS, and Tom Valleau, MA, Whitespace Ltd, Alexandria, Virginia, provided the contact data. Maciej Boni, PhD, Pennsylvania State University, and Albert I. Ko, MD, Yale School of Public Health, provided helpful comments on the manuscript. Jennifer Widness, JD, and Maura Provencher, MS, Connecticut Conference of Independent Colleges, provided data on COVID-19 testing and cases. Suzanne Onorato, PhD, University of Connecticut, provided data on COVID-19 testing and cases. Alice Pritchard, PhD, Connecticut State Colleges and Universities, provided data on COVID-19 testing and cases. Jessica Brockmeyer, PhD, Connecticut Department of Public Health, provided town COVID-19 case data. Alexandra Edmundson, MPH, Connecticut Department of Public Health, provided context for data during group discussions. Samantha Dean, BA, Yale School of Public Health, assisted in managing the contact data. No one was financially compensated for the stated contribution.
                Article
                zoi211140
                10.1001/jamanetworkopen.2021.40602
                8703252
                34940864
                05045f70-77a1-474c-bde6-cf55b6018252
                Copyright 2021 Schultes O et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 6 August 2021
                : 30 October 2021
                Funding
                Funded by: Centers for Disease Control and Prevention
                Funded by: COVID-19 Paycheck Protection Program and Health Care Enhancement Act
                Funded by: Eunice Kennedy Shriver National Institute of Child Health and Human Development
                Funded by: Pershing Square Foundation
                Categories
                Research
                Original Investigation
                Online Only
                Infectious Diseases

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