As the COVID-19 pandemic continues to take lives across the USA, colleges continue to plan their reopening in the fall. Most colleges are putting together strategies to prevent future outbreaks of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Now, a new study by researchers at California Institute of Technology and Johns Hopkins University and published on the preprint server medRxiv* in August 2020 shows that poorly planned and inadequate testing approaches to mitigate viral spread among the returning university students are likely to result in epidemics that will plague the country for a long time.
*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
The current situation
Already, even with students mostly out of campus, several flare-ups have occurred, providing a glimpse of the much larger epidemics that could follow the gathering of hundreds of thousands of students freely mixing, studying, and playing together on campus and in the surrounding cities and towns. Even as many institutions have already made their mitigation plans public, it is proving difficult to understand just what underlies these strategies.
The current study focuses on one component of these plans: on-campus testing. The researchers assessed testing plans released by over 500 colleges and universities in various parts of the country, from a medley of testing plans for over 1,200 institutes of higher education published in the Chronicle. In addition, they examined statistics of transmission and text from websites directed at the public.
Muddled and variable strategies
The result? The researchers describe it as “a highly variable and muddled state of COVID-19 testing plans among US institutions of higher education that has been shaped by discrepancies between scientific studies and federal guidelines.”
The researchers say that in several cases, the testing strategy is not compatible with the best practices recommended by public health authorities, and may pose questions of bioethics. The range of testing covers no testing to regular testing for students, staff, and faculty.
Testing or no testing
Overall, over half the universities planned to do or provide access to testing in some form for SARS-CoV-2. However, only a little more than a quarter planned to test all undergraduates at the time of reopening, that is, at baseline. Only one in five colleges even plan regular testing, whatever the timeline of regularity may look like.
Secondly, there was a clearly drawn geographical line, demarcating testing from non-testing universities. Thus, those institutions in the Northeast have recorded their commitment to far more testing than others. Many of these institutes depend on the Broad Institute for their testing, because of the capacity it has built in the pandemic. The researchers describe this: “11 schools in Massachusetts, three in New York, two in Maine, one in Rhode Island, and one in Connecticut are all contracting with the Broad Institute to perform their testing.”
The five states at the top, concerning the number of institutions, are Massachusetts, New York, Pennsylvania, California, and Texas. However, the researchers found that among these states, where they had the most substantial amount of information available, there was an inverse correlation between planned testing at re-entry and the COVID-19 test positivity rate.
If testing is done for all students initially, but infectious students are not quarantined, there could be outbreaks just the same, the investigators point out.
Why is there so much confusion?
The researchers comment, tongue-in-cheek, “The variability of testing strategies might lead one to conclude that there is uncertainty in the science of best practices for the safe reopening of colleges.” The truth is that much current research focuses on this area, providing guidelines for the kind of testing required. This can be best described as readily available and frequent testing facilities to ensure a safe reopening.
The problem is twofold: one is due to the lack of a uniform policy, while the other is financial. First, there is no unified policy on testing prescribed on a national basis for colleges and universities. Secondly, the cost of a COVID-19 test is set by the Centers for Medicare and Medicaid Services for all practical purposes. This has led institutions to consider how to squeeze the maximum utility, dollar-wise, out of each test, rather than maximizing the public health value of each test.
Testing or Quarantine?
Many institutes have adopted a 14-day quarantine either together with or instead of testing students at the time of re-entry. Another option is to ask for viral RNA tests (using reverse transcriptase-polymerase chain reaction, RT PCR) taken at a specified time period before the students enter the campus. However, there is no consensus on the period in which the test must be done.
For instance, New York’s Syracuse University allows only a 10-day window before the test result loses its validity. However, Simpson College in California has a 30-day window. And at USC, there is no need to test again within a 90-day test window prior to re-entry. These recommendations ignore the current lack of consensus on the duration for which neutralizing antibodies may persist following COVID-19 infection.
Other universities are planning to use, in addition, as yet unproven methods such as pooled samples of environmental DNA for testing, like the University of South Florida. And wastewater testing is the method of choice for Michigan Tech.
Frequency of Testing
The world over, scientists are relying on the most sensitive available PCR tests for case detection. However, there is a suggestion, based on more recent research, that repeated and rapid testing is more important than 100% sensitivity, where COVID-19 testing is concerned. In fact, research on the frequent testing approach for university campuses, in particular, shows that if college communities are tested once in two days, outbreaks on these campuses could be contained.
In the US, however, few colleges even plan to do regular screening of all students, staff, and teachers. And among these few, there is no agreement as to the frequency with which such testing should be carried out.
The Cost of Health
Of course, cost plays a dominant role in such decision-making, as cited by the Chancellor of the California State University system, Timothy White, defending the decision to hold only online classes for the fall semester in view of the $25 million costs of weekly testing for half the students at all the campuses – which is beyond the system’s financial capacity. Others have bought enough tests for 300 people to be tested daily throughout this semester.
Another issue relates to the lack of unified government policies. While the Center for Disease Control and Prevention (CDC) deals with matters such as surface decontamination, communication, and contact tracing on college campuses, it continues to present COVID-19 testing as an “interim consideration.” This does not take into account the plentiful research already available on the role played by frequent testing at regular intervals on successful containment.
The CDC thus treats the issue as a non-recommended measure based on the lack of evidence, justifying it by stating it to be “unknown if entry testing in institutes of higher education provides any additional reduction in person-to-person transmission of the virus.” Consequently, the CDC says it does not recommend such testing. And this is being used as grounds for universities to refuse to test adequately.
The University of North Carolina at Chapel Hill quotes CDC guidelines while putting the onus of preventing viral spread on the students, workers, and staff. Some surprising quotes defending zero testing policies include the description of universal testing as conferring “a false sense of security,” “the tests cannot provide assurance that someone will not become sick after the test is performed,” and “mass screening has limited efficacy (as it only establishes a result in a moment in time).”
Inequity Shows up in Testing Differences
As with other areas of US healthcare, the COVID-19 pandemic has brought to the forefront the lack of fairness with which heath resources are distributed among different segments of society. This is now becoming obvious in the field of higher education, where resource-rich private universities plan to test, at 37%, vs. straitened public universities at 16%.
Moreover, almost all the top 50 (US News World Report) US colleges/universities plan some form of testing compared to less than half of the lower-ranked institutions. Endowments also play their role, obviously, as higher endowments are associated with a higher chance of testing being included in reopening plans than smaller ones.
Even within universities, the failure to confirm if staff and low-wage workers on campus are being offered testing is a glaring omission. This only repeats the pattern visible since the start of the pandemic, with so-called essential workers in many low-paying jobs, who typically are from other than white communities, being exposed to higher risk but with less chance of getting access to testing or medical care. These workers have a higher rate of complications, as well. These temples of learning are thus strengthening disparities and injustice in society rather than removing them.
Students and staff are seen as part of the academic program rather than as individuals whose safety matters. This is glaringly obvious in the way Pennsylvania State University treats the re-entry of its 40,000 students as a “research opportunity,” enabling the pandemic to be studied in real-time. Some small university towns think this will be a public health crisis, instead, given the already documented propensity of younger Americans to disregard containment norms and exercise liberty of movement unfettered by public health recommendations.
Implications
The researchers caution that such a crisis can be averted “only with urgent action on the part of Federal and state authorities, working in concert with university administrators.” They advocate for scientific and ethical considerations to rule, to develop a transparent and universal approach to testing, making access available for all stakeholders in a university community.
*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
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