A Fall Like No Other

Sewanee: The University of the South finished the in-person portion of the fall semester with 16 positive cases among students.

The liberal arts college in Tennessee credits its relatively low case numbers to weekly required COVID testing for the approximately 1,600 students on campus combined with a “bubble” approach that largely prohibited students from leaving campus except for essential activities such as medical appointments. Students had to formally request approval from the dean of students' office for any off-campus trips, and a student caught violating the rules by breaching the bubble and leaving the campus without permission, or hosting a guest from off campus, would have to leave campus to quarantine for two weeks and be retested before rejoining the bubble.

Over the course of the semester, 26 students were sent home for two weeks for bubble-related infractions. Lauren Goodpaster, assistant dean for campus life, said Sewanee tried to increase on-campus entertainment options and make accommodations for students’ needs and wants. Food trucks were brought to the campus. Campus officials negotiated with restaurants that don’t typically deliver to provide delivery to students. Twice-weekly Walmart runs by campus life staff were provided to pick up student orders. Goodpaster said the college’s outing club also increased the number of outdoors trips it offered on the university’s 13,000-acre campus.

“We are a residential liberal arts college on top of a mountain plateau in a rural setting,” said David Shipps, Sewanee’s vice president for risk management. “You can’t ask for a better set of circumstances to attempt to create a bubble, which was essentially intended to reduce the risk of introducing the virus on campus. That’s where we focused our efforts over the course of the semester."

He's convinced it worked. Apart from the required COVID testing of students, Sewanee offered voluntary testing for employees who wanted it; a total of 24 faculty and staff tested positive over the course of the semester.

"Like so many other institutions, we had quite a bit of uncertainty, and we were all wanting to finish the semester together on campus," Shipps said. "But there was just so much uncertainty back in August. It seems like so long ago, but it wasn't."

With the semester drawing to a close -- and many colleges having concluded in-person instruction before Thanksgiving -- college leaders are starting to share stories of what they think worked well this past semester for keeping COVID spread on campuses under control.

Colleges unquestionably had very different degrees of success in keeping the virus in check, and luck no doubt played a role in how different colleges fared. It's difficult to make cross-institutional comparisons, not least because it's impossible to make precise statements about the prevalence of disease at those colleges that did not do frequent, broad-based testing.

The semester started inauspiciously when the University of North Carolina at Chapel Hill, facing a cluster of cases that all but filled its quarantine rooms, told students to move out of the dorms and shifted classes online about a week after the semester began. Throughout the semester, there were periodic announcements from colleges about temporary or semester-long shifts to remote learning or dormwide quarantines. Others stayed the course for in-person learning even as they reported high numbers of active cases.

Other colleges reported comparatively fewer case numbers -- or even, in at least one instance, no cases at all. One theme that became increasingly apparent over the course of the semester in research and anecdotal accounts alike is the importance of frequent testing to identify cases before they can fuel outbreaks.

Connecticut College, a liberal arts institution, tested students twice weekly and faculty and staff once or twice weekly depending on the number of days a week they were on campus. It was one of more than 100 colleges that partnered with the Broad Institute, a nonprofit research institution in Cambridge, Mass., that provided testing to colleges at the relatively low cost of $25 a test.

“It just became part of everybody’s week to go down to the testing center twice a week,” said Victor Arcelus, the dean of students at Connecticut College. “That allowed everyone to be able to do what they did over the course of semester. Knowing what the positivity rate was on our campus at any given time, it enabled us to hold in-person classes, it enabled us to have student clubs. Our varsity athletes were able to engage in in-person training, and ultimately we were able to do some inter-squad scrimmages.”

Of the 64 positive student cases on campus over the fall, Arcelus said 10 of those were identified as originating cases, in which students were believed to have contracted the virus through various means -- including through a family visit, a plane trip and, in six cases, exposure at a local restaurant -- and to have spread the virus on campus.

“When we ran our data, 87 percent of those additional cases beyond those originating cases were already in quarantine at the time that they turned positive, which goes to show how effective the contact tracing was,” Arcelus said.

The University of Illinois at Urbana-Champaign also tested students frequently. Having conducted more than a million tests this semester, the university is now testing undergraduate students every other day (the frequency recommended in an influential modeling study published last summer) and faculty, staff and graduate students twice per week.

Students and employees have to scan a pass indicating a recent negative test in order to access campus buildings. They also could opt in to digital exposure notifications on an app that uses mobile phone technology to alert them to get tested based on the length of time they were in close proximity to another individual who tested positive.

After a spike in cases in early September, UIUC went into partial lockdown, ordering undergraduate students to stay in their residences other than essential purposes like going to class, purchasing groceries, exercising outdoors, attending religious services or going to medical appointments.

"Then we ended up at a really good, steady state," said Martin Burke, chair of UIUC’s testing effort and the May and Ving Lee Professor for Chemical Innovation. "By mid-October we were down to 0.05 percent positivity one day -- we had two cases one day; we almost eradicated it on our campus. After case numbers began increasing in late October and early November, the university increased the testing frequency for employees and asked students and employees to limit their social activities again for two weeks.

“The lesson learned is how important it is to have the data, and have a team monitoring the data to make adjustments,” said Burke, who emphasized that testing was just one piece of a larger strategy. “It’s a simple formula: fast, frequent testing, masks and distancing -- these three things can do it, and you add contact tracing and now you get an extremely robust system and you can reopen safely.”

The university is advising other colleges on building and expanding their own testing programs.

“It’s the testing, plus -- it’s the whole ecosystem that makes it successful,” said Bill Jackson, who is managing the Shield T3 project, which is helping other universities set up a testing system. “I think a lot of universities have not been successful and they’ve been kidding themselves because they don’t understand the [amount of] infection across their student body. I think it’s a lot larger than people report if they don’t do complete surveillance-based testing, and the issue with that is for the most part the students do OK, but the potential spread into the community and their families is high.”

An analysis published last weekend in The New York Times found that deaths from COVID rose at faster rates in counties that are home to colleges. Since the end of August, deaths have doubled in counties with large college-aged populations, compared to a 58 percent increase in the rest of the country. Few college students have died; most who have died are older people or those living and working in the communities where the colleges are located.

“I think most people realize the more testing, the better,” said Gerri Taylor, co-chair of the American College Health Association’s task force on COVID-19. She also emphasized the importance of other preventative measures including mask mandates and social distancing requirements, the de-densification of classrooms and residence halls, and modification of dining operations.

“The big question for me is does every college have the financial ability to do this in terms of the costs of the test, the labs, the staffing to do the tests, to notify the students,” Taylor said. "There’s a whole infrastructure that has to be in place, and the more you do it, the more infrastructure you need. To me that’s the big issue.”

Relatively few colleges are testing on the scale of UIUC or Connecticut College. Data from the College Crisis Initiative, a research institute based at Davidson College in North Carolina that has studied colleges’ responses to COVID, show that just 128 of the nation's four-year colleges are testing students weekly, and very few are testing more than once a week. Testing extensively can be an expensive proposition: even at $25 a test, the cost established by the Broad Institute, that quickly multiplies for colleges that test all students and employees once or twice a week.

Researchers at Duke University in North Carolina published an article in a Centers for Disease Control and Prevention publication in November highlighting the importance of broad testing across campus given the potential for spread by asymptomatic or presymptomatic individuals. The researchers reported that slightly more than half (51 percent) of the 84 total students who tested positive were asymptomatic, suggesting "that a substantial proportion of infections would be missed with only symptomatic testing."

Duke used a pooled testing strategy, combining five samples into a single test, and flagging positive tests for further testing of each of the component samples.

The University of California, San Diego, has implemented a variety of testing strategies, even going so far as to stock self-administered test kits in vending machines. Starting Jan. 1, students will be required to do a self-administered test once a week.

UCSD, which currently requires students living on campus and attending in-person classes to take a COVID test every 12 to 16 days, has also expanded its capacity to test for viral traces in wastewater, increasing its number of wastewater samplers from six to 52 to cover more than 100 residential buildings, with plans to expand further to cover the whole campus. After UCSD flagged traces of the virus coming from nine buildings in late November -- a combination of residential and nonresidential buildings -- the university reports that it notified residents of those buildings and more than 700 students were tested.

UCSD plans to invite more students to live on campus next spring, increasing the number from about 9,500 to 11,000 or 11,500, according to the chancellor, Pradeep Khosla. More than 90 percent of UCSD's classes last fall were held remotely.

“I personally think it went way better than I would have imagined,” Khosla said. “There were no outbreaks on campus; the positivity rate on campus has gone up a little bit, but it’s way less than outside” campus. UCSD reports its positivity rate ranged from 0.17 to 0.49 percent during the fall quarter, which concluded Nov. 29, compared to positivity rates of between 2.7 and 6.1 percent in San Diego County.

Looking ahead to the start of the spring semester, colleges stand to face bigger challenges than they did in the fall.

"There will likely be more COVID in our city, region and state in February when we return than there was in August when we started in the fall,” said Arcelus of Connecticut College. “The onboarding process is going to be pivotally important. We’re asking students to self-isolate in the two weeks before they come to campus to try to avoid settings in which they might contract the virus, and then they’ll do a prearrival test and then they’ll arrive on campus and when they come to campus immediately have a test.”

Burke, of UIUC, said the university will be doing a phased re-entry, bringing in freshmen, then sophomores, then juniors, then seniors, each four days apart, and will restrict students to just essential activities for the first three weeks of the semester. “The key is we want to avoid that initial spike” in cases, he said.

Complicating the return to campus will be the fact that in much of the country the start of the spring semester will happen during cold weather, when students will by and large be indoors. That worries Darron Collins, president of College of the Atlantic, in Maine, which finished the fall semester with zero cases on campus among its approximately 500-person community of faculty, students and staff. (There was one positive test result, but the college says that after consulting with its medical professionals, they determined that the student had recovered from a COVID case contracted over the summer but continued to test positive.)

The College of the Atlantic, which also partners with the Broad Institute, made the decision to test all students, faculty and staff twice the week they arrived and subsequently test 20 percent of students, faculty and staff per week, a proportion that Collins said will increase to 25 percent next semester. The college spent about $90,000 on testing in the fall.

"We’re a small school on a very tight budget," Collins said, adding that the decision to test about 20 percent of students and employees each week "got us the sweet spot that we needed. Would we have liked to test everyone every week? Of course, that provides more data and generally more data is a good thing, but we thought this was an appropriately cautious and cost-effective way to make sure the community was safe."

There’s no question College of Atlantic benefited from geography -- COVID rates in Maine remained lower than in most of the rest of the country throughout the fall -- but Collins credits College of the Atlantic's socially minded students with making the fall work.

“Their vigilance and their seriousness is why we were successful,” he said. “I’m not overstating that. They really wanted to be here for the fall, they really want to be here for the winter; in-person on campus instruction is what we’re all about, so there was a quid pro quo -- well, if we’re going to do that, we really need active vigilance among the student body. And they responded.”