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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


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


          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.


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



          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.


          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.


          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.


          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.


          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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          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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            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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              Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans — Los Angeles, California, 2020

              On March 28, 2020, two residents of a long-term care skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) had positive test results for SARS-CoV-2, the cause of coronavirus disease 2019 (COVID-19), by reverse transcription–polymerase chain reaction (RT-PCR) testing of nasopharyngeal specimens collected on March 26 and March 27. During March 29–April 23, all SNF residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal SARS-CoV-2 RT-PCR testing, and positive results were communicated to the county health department. All SNF clinical and nonclinical staff members were also screened for SARS-CoV-2 by RT-PCR during March 29–April 10. Nineteen of 99 (19%) residents and eight of 136 (6%) staff members had positive test results for SARS-CoV-2 during March 28–April 10; no further resident cases were identified on subsequent testing on April 13, April 22, and April 23. Fourteen of the 19 residents with COVID-19 were asymptomatic at the time of testing. Among these residents, eight developed symptoms 1–5 days after specimen collection and were later classified as presymptomatic; one of these patients died. This report describes an outbreak of COVID-19 in an SNF, with case identification accomplished by implementing several rounds of RT-PCR testing, permitting rapid isolation of both symptomatic and asymptomatic residents with COVID-19. The outbreak was successfully contained following implementation of this strategy. VAGLAHS includes 150 long-term care beds in three SNF patient care areas, or wards; SNF wards A and B are in building 1, and ward C is in building 2. Buildings 1 and 2 do not share common areas, but residents might have indirect contact with outside persons while receiving medical services such as dialysis. These wards admit residents who require intravenous antibiotics, complex wound care, other rehabilitation needs, routine dialysis, chemotherapy, or radiation therapy; underlying conditions, including chronic obstructive pulmonary disease, hypertension, cardiovascular disease, and chronic kidney disease, are common. At the time of the outbreak, 99 (66%) beds were occupied; >95% of residents were men aged 50–100 years. All data were abstracted from the VAGLAHS electronic health record system on which all records are maintained on inpatients, SNF residents, and outpatients. To reduce the risk for introduction of SARS-CoV-2, on March 6, all VAGLAHS staff members and visitors were screened for symptoms of COVID-19 (i.e., fever, cough, or shortness of breath), travel to countries that had CDC travel warnings for COVID-19, and any close contact with persons with known COVID-19; those with relevant symptoms or exposures were not allowed entry to any area of the facility. On March 11, all SNF admissions were suspended, and daily temperature and symptom screening began for all residents. Residents with fever or lower respiratory tract signs or symptoms were placed on droplet and contact precautions in single-person rooms. On March 17, visitors were prohibited from entering any SNF building. On March 26, the index patient (patient A0.1 † ) in ward A developed fever. A second ward A patient (patient A0.2) developed fever and cough on March 27. Nasopharyngeal swabs collected the day of fever onset were reported as positive for SARS-CoV-2 for both patients A0.1 and A0.2 on March 28. In response, during March 29–31, VAGLAHS staff members screened all building 1 (wards A and B) residents, regardless of symptoms, by SARS-CoV-2 RT-PCR testing of nasopharyngeal swabs. On March 29, a resident from ward C (C0.1) in building 2 became symptomatic; SARS-CoV-2 RT-PCR nasopharyngeal testing was positive on March 30, prompting testing of all building 2 residents on March 31. All three residents with a diagnosis of COVID-19 (patients A0.1, A0.2, and C0.1) were transferred to the affiliated acute care hospital for isolation and clinical management. Implementation of infection control procedures (i.e., hand hygiene, droplet and contact precautions for persons with fever or lower respiratory tract signs or symptoms), and strategies for case identification and containment were reviewed with SNF staff members. Although staff members could previously be assigned to daily shifts on different wards, beginning on March 28, each staff member was assigned to a single ward. During the outbreak, an infection control nurse regularly reviewed and monitored the use of recommended personal protective equipment (PPE) with all SNF staff members. Protocols for use of PPE, based on CDC guidance, § did not change during the outbreak. All staff members were screened by RT-PCR at least once during March 29–April 10. RT-PCR Testing of Residents RT-PCR testing of all residents, conducted during March 29–March 31 in wards A, B, and C, identified SARS-CoV-2 in four (13%) of 30 residents on ward A, none of 30 residents on ward B, and 10 (28%) of 36 residents on ward C. All infected residents were transferred to the affiliated hospital for isolation and clinical management, and the wards were closed to new admissions. Following the initial testing, some residents moved between the SNF and the affiliated hospital for treatment of medical conditions unrelated to COVID-19. Considering the number of cases identified through initial testing, the Infection Control team, in coordination with the SNF nursing staff members, implemented serial (approximately weekly) RT-PCR testing among residents of wards A and C until no additional residents received a positive test result. On April 3, all 22 remaining ward A residents received negative test results and were subsequently transferred to wards B and C. Ward A was converted into a COVID-19 recovery unit to cohort patients without acute hospital needs with continued RT-PCR–positive test results during convalescence. On April 6, the 28 residents on ward C were retested; two had positive test results and were transferred to the COVID-19 recovery unit (Box). A third round of testing was performed on ward C on April 13; all 27 residents had negative test results. During April 22–23, a final round of testing conducted on wards B and C identified no positive test results among the remaining 83 residents. BOX Discharge criteria for Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) facility patients with positive test results for SARS-CoV-2 and criteria for transfer back to acute care hospital — Los Angeles, California, 2020 Required criteria for discharge from acute care to COVID-19 recovery unit * Confirmed COVID-19 diagnosis During the preceding 2 days Temperature 93% or no change from established baseline for residents with chronic oxygen requirement for 24 hours before transfer D-dimer 99.9°F (>37.7°C) Respiratory rate ≥24 per minute Abbreviations: COVID-19 = coronavirus disease 2019; FEU = fibrinogen equivalent units; SNF = long-term care skilled nursing facility; VA = Veterans Affairs. * Laboratory tests are not required for asymptomatic comfort care residents who are otherwise candidates for transfer to the COVID-19 recovery unit. † A test-based strategy is preferred for discontinuation of transmission-based precautions for residents who are being transferred to a long-term care or assisted living facility. All testing must be complete before transfer. In total, three residents were identified with COVID-19 based on testing conducted because of symptoms, and 16 additional residents were identified with COVID-19 because of RT-PCR testing, two of whom reported or were identified with symptoms at the time of RT-PCR testing (Table). Fourteen of the 19 (74%) residents with COVID-19 reported no symptoms at the time of testing; among these residents, eight were presymptomatic, developing symptoms 1–5 days after the date of specimen collection. One of the three initially identified patients, C0.1, a man aged >90 years, died. TABLE Characteristics of long-term care skilled nursing facility residents with positive test results for SARS-CoV-2 (N = 19) — Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, 2020 Characteristic No. (%) Asymptomatic* (n = 6) Presymptomatic* (n = 8) Symptomatic* (n = 5) All (N = 19) Demographic Age, yrs, median (IQR) 75 (72–75) 67 (66–84.5) 84 (70–85) 75 (66–85) Male sex 6 (100) 8 (100) 5 (100) 19 (100) Race/Ethnicity† Asian — — — — Black or African American 2 (33) 4 (50) 2 (40) 8 (42) Native Hawaiian or Pacific Islander — 1 (13) — 1 (5) White 3 (50) 3 (38) 2 (40) 8 (42) Unknown 1 (17) — 1 (20) 2 (11) Hispanic — — — — Underlying medical condition§ Hypertension 5 (83) 5 (63) 3 (60) 13 (68) Cardiovascular disease 3 (50) 4 (50) 5 (100) 12 (63) Diabetes 4 (67) 5 (63) 2 (40) 11 (58) Body mass index >30 kg/m2 3 (50) 2 (25) 2 (40) 7 (37) Chronic kidney disease (stage 4 or above) — 2 (25) 1 (20) 3 (16) Chronic obstructive pulmonary disease 1 (17) 1 (13) 2 (40) 4 (21) Symptoms at time of or after testing¶ Constitutional symptom — 6 (75) 5 (100) 11 (58) Fever — 6 (75) 5 (100) 11 (58) Myalgia — — 1 (20) 1 (5) Headache — 1 (13) 1 (20) 2 (11) Respiratory symptom — 4 (38) 5 (100) 9 (47) Cough — 2 (25) 5 (100) 7 (37) Dyspnea — 2 (25) 1 (20) 3 (16) Gastrointestinal symptom — 5 (63) 1 (20) 6 (32) Nausea — 1 (13) — 1 (5) Emesis — 1 (13) — 1 (5) Diarrhea — 2 (25) — 2 (11) Poor appetite — 3 (38) 1 (20) 4 (21) Laboratory findings on admission,**,†† median (IQR) [No.] WBC (x 1,000/μL) 4.32 (3.67–5.91) [5] 4.35 (3.93–6.10) [8] 6.24 (6.09–7.08) [5] 5.32 (3.94–6.20) [18] Lymphocytes (%) 31.5 (26.4–32.7) [5] 22.0 (17.5–25.9) [8] 16.7 (11.4–16.9) [5] 22.0 (17.0–30.3) [18] Lymphocytes (x 1,000/μL) 1,200 (1,140–1,200) [5] 960 (775–1,105) [8] 880 (770–1,200) [5] 1,025 (835–1,200) [18] Creatinine (mg/dL) 1.00 (0.89–1.05) [4] 1.01 (0.82–1.07) [8] 2.84 (1.99–3.23) [5] 1.04 (0.88–1.41) [17] AST (U/L) 19 (17–21) [3] 24 (20–29) [5] 31 (NA) [1] 22 (19–29) [9] ALT (U/L) 16 (13–21) [4] 17 (14–44) [6] 28 (21–28) [3] 16 (14–28) [13] D–Dimer (μg/mL FEU) 0.54 (0.42–0.83) [4] 0.66 (0.55–1.42) [7] 0.94 (0.59–1.17) [3] 0.63 (0.50–1.29) [14] Ferritin (ng/mL) 60.8 (51.2–99.7) [5] 343.0 (162.5–540.6) [8] 184.6 (NA) [2] 179.1 (59.0–354.2) [15] CRP (mg/dL) 0.605 (0.420–1.190) [4] 1.070 (0.900–2.565) [7] 6.765 (NA) [2] 1.03 (0.71–2.63) [13] Outcomes Supplemental oxygen required — 4 (50) 4 (80) 8 (42) Death — — 1 (20) 1 (5) Length of hospital stay, days, median (IQR) 6 (1–6) 9 (7–10) 10 (5–13) 6 (5–10) Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; CRP = C-reactive protein; FEU = fibrinogen equivalent units; IQR = interquartile range (1st–3rd); NA = not applicable; WBC = white blood cell. * Patients were classified as symptomatic if they had at least one listed symptom at the time of first positive specimen collection, presymptomatic if they did not exhibit symptoms at the time of specimen collection but later developed at least one listed symptom, and asymptomatic if they did not exhibit symptoms at any time between specimen collection and the last date of data collection. † Asian, black, Native Hawaiian or Pacific Islander, and white residents in this cohort were non-Hispanic; Hispanic persons could be of any race. § Comorbidities were determined based on documented SNOMED CT and International Classification of Diseases, Ninth Revision codes and review of patient’s vital signs, laboratory values, imaging findings, and provider notes. Chronic kidney disease stage was calculated using the Cockcroft-Gault equation to determine creatinine clearance; patients with estimated glomerular filtration rates 100.4°F (>38°C) or fever reported by provider. ** These values include the first available laboratory results within 48 hours of admission for each patient. †† Reference values are as follows: WBC = 4.5–11.0 x 1,000 per μL; lymphocytes = 600–4,800 x 1,000 per μL; % lymphocytes = 20%–40%; creatinine = 0.66–1.28 mg per dL; AST = 13–35 U per liter; ALT = 7–45 U per liter; d-Dimer = 0.00–0.42 μg per mL FEU; ferritin = 22–322 ng per mL; CRP = 0–0.744 mg per dL. RT-PCR Testing of Staff Members During March 29–April 10, universal RT-PCR testing of all 136 staff members identified eight (6%) infections: three in registered nurses and five in licensed vocational nurses, all of whom worked in wards A or C. Four of the eight infected staff members were symptomatic and were tested within 2 days after symptom onset; one developed fever at work and was immediately tested and sent home. None of the others worked during or after symptom onset. Although serial RT-PCR testing of staff members was not feasible because of limited testing supplies, testing remained available for symptomatic staff members. No cases among staff members were identified after the initial round of testing. Discussion During March 26–April 23, a total of 19 cases of COVID-19 were diagnosed among 99 SNF residents (19.2%). At the time of diagnosis, 14 of 19 residents were asymptomatic, eight of whom were presymptomatic; one patient died. One half of the eight staff members with a diagnosis of COVID-19 were initially asymptomatic. This report demonstrates the high prevalence of asymptomatic SARS-CoV-2 infection that can occur in SNFs, highlighting the potential for widespread transmission among residents and staff members before illness is recognized and demonstrating the utility of universal RT-PCR testing for COVID-19 after case identification in this setting. SNFs and other long-term care facilities where residents have high rates of underlying medical conditions are particularly susceptible to COVID-19 outbreaks ( 1 – 3 ). Limited testing and delayed recognition of symptomatic cases in congregate living settings can result in large and protracted outbreaks ( 3 ). In a recently described outbreak within homeless shelters, RT-PCR testing of all residents, coupled with rapid isolation and cohorting procedures, limited transmission ( 4 ). Multiple studies have demonstrated efficient transmission of SARS-CoV-2 from infected persons who are not yet symptomatic ( 1 , 5 , 6 ). One study in Italy showed through community surveillance testing that 43% of persons with confirmed SARS-CoV-2 infection were asymptomatic and that transmission from asymptomatic and presymptomatic persons also occurred within households. ¶ In this cohort, transmission from asymptomatic persons was likely, because a large proportion of residents and staff members did not have symptoms at the time of diagnosis. RT-PCR testing among SNF residents was repeated approximately weekly until all residents had negative test results. Serial testing aided the identification of subsequent cases. Testing of staff members might be especially important because they can acquire SARS-CoV-2 in the community and reintroduce it into the SNF. Although serial laboratory testing of staff members was considered after the initial round of testing, insufficient supplies limited the ability to fully carry this out. Swift isolation and cohorting of residents with COVID-19 reduced further transmission within the SNF; residents who had positive test results were quickly transferred out of the SNF, either to the acute care hospital or directly to a separate COVID-19 recovery unit. The conversion of ward A into a COVID-19 recovery unit allowed cohorting of clinically stable residents within the SNF without requiring transfer to the affiliated hospital. This measure decreased burden on the hospital and allowed residents to remain in a familiar setting. Restricting staff movement between SNF wards reduced potential for transmission between wards. With these measures, the outbreak in ward A was suppressed within 1 week, the outbreak in ward C was suppressed within 2 weeks, and no cases occurred in ward B. The Centers for Medicare & Medicaid Services currently recommends symptom screening of all SNF patients and cohorting of staffing teams for infected and uninfected patients ( 7 ). Medicare has expanded coverage for SARS-CoV-2 tests ( 7 ), and, as of April 30, Los Angeles County Department of Public Health had endorsed mass testing if a COVID-19 case is identified in a long-term care facility ( 8 ). At the time of the VAGLAHS SNF outbreak, the Los Angeles County Department of Public Health criteria for testing did not include RT-PCR testing of asymptomatic persons ( 9 ). The findings in this report are subject to at least three limitations. First, because residents’ recall might be limited by cognitive disorders or recall bias, over- or underreporting of symptoms was possible and could have affected classification of patients as symptomatic or asymptomatic. Second, symptom data obtained from medical records might have been incomplete, because the daily symptom screening only included fever and respiratory symptoms and did not include symptoms more recently recognized as being associated with COVID-19, such as loss of sense of smell or taste,** which could have led to an overestimation of the asymptomatic population. Finally, because the all-male cohort of patients with laboratory-confirmed COVID-19 might have comorbidity profiles that differ from other groups, these findings might not be generalizable to other SNFs. This investigation demonstrates the benefit of RT-PCR testing of SNF residents and staff members for SARS-CoV-2 after an initial case of COVID-19 is diagnosed. Identification of asymptomatic COVID-19 cases after initial RT-PCR testing supports implementation of serial laboratory testing in SNFs where COVID-19 cases have been identified. Identification of asymptomatic and presymptomatic residents with positive laboratory results for SARS-CoV-2 facilitated rapid transfer of these residents out of the SNF until a dedicated ward to cohort those with COVID-19 was created within the SNF, thereby reducing transmission. In congregate living settings that include persons with conditions that might place them at high risk for severe COVID-19, universal and serial laboratory-based testing for SARS-CoV-2 is an effective strategy that can be implemented for rapid identification of infection to minimize transmission. Summary What is already known about this topic? Long-term care skilled nursing facilities (SNFs) are at high risk for COVID-19 outbreaks. Many SNF residents and staff members identified with COVID-19 are asymptomatic and presymptomatic. What is added by this report? After identification of two cases of COVID-19 in an SNF in Los Angeles, universal, serial reverse transcription–polymerase chain reaction (RT-PCR) testing of residents and staff members aided in rapid identification of additional cases and isolation and cohorting of these residents and interruption of transmission in the facility. What are the implications for public health practice? Universal and serial RT-PCR testing in SNFs can identify cases during an outbreak, and rapid isolation and cohorting can help interrupt transmission.

                Author and article information

                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                23 December 2021
                December 2021
                23 December 2021
                : 4
                : 12
                [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.
                Copyright 2021 Schultes O et al. JAMA Network Open.

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

                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
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