Disparities in Testing

Colleges are planning a wide range of COVID-19 testing strategies, ranging from frequent universal testing to no campus-based testing at all. Variation of approaches raises questions about equity.

August 21, 2020
 
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Different colleges are planning a wide range of COVID-19 testing approaches this fall. Some are planning on twice-weekly testing of students or employees, while others have no plans to offer COVID testing on the campus at all.

Such variations can be seen in microcosm across the University System of Georgia. Georgia Institute of Technology, a major STEM-focused research university, is offering free diagnostic testing for symptomatic faculty, students and staff and planning for surveillance testing that will allow it to test up to 1,500 asymptomatic students, staff and faculty a day. Meanwhile, Georgia Gwinnett College, a regional public baccalaureate-level university, does not offer testing on campus but advises students that it is available for free through the Georgia Department of Public Health and may also be available through their primary care physician or pharmacy.

Lance Wallace, a spokesman for the University System of Georgia, said the system worked with its various universities “to make sure that testing is available through all the institutions, but what that looks like is different. In some cases, the institutions have the resources to offer the test there on campus in campus health facilities. In other institutions, they don’t have those resources so they have partnered with outside agencies or organizations. In some cases there is a Department of Health testing site co-located or nearby the campus.”

“It is all over the place,” Gerri Taylor, co-chair of the American College Health Association’s task force on COVID, said of the various testing programs. She said the task force has “agonized” over whether to recommend colleges perform testing beyond the amount recommended by the Centers for Disease Control and Prevention.

The CDC's interim guidance to colleges on testing recommends testing of symptomatic students and employees and those who have known or suspected contact with an infected individual. The CDC does not recommend testing upon students' re-entry to campus, which many universities are doing, saying it is "unknown if entry testing in IHEs provides any additional reduction in person-to-person transmission of the virus beyond what would be expected with implementation of other infection preventive measures."

The agency makes no recommendation in regard to broad surveillance testing of asymptomatic students and staff over the course of a term, though it notes institutions may consider this strategy in areas with moderate to substantial community transmission "to identify outbreaks and inform control measures."

Taylor, who is also the former associate dean and student health center director at Bentley University, in Massachusetts, believes surveillance testing of all students and employees multiple times a week "would be great in an ideal world; however it's extremely costly."

“This is a topic that keeps coming up, but we recognize that there are many small and medium-sized colleges that could not support this type of strategy,” she said. “What we need is more cost-efficient tests, more availability.”

Lior Pachter, the Bren Professor of Computational Biology and Computing and Mathematical Sciences at California Institute of Technology and an author of a new article examining colleges’ diverse approaches to testing, sees availability of testing on campus as an equity issue.

Pachter and his co-authors published a preprint of an article last week based on their analysis of 500 college reopening plans. They found that 27 percent of the colleges plan on testing undergraduates upon their return to campus, while 20 percent “plan to test their communities regularly to some extent.” They found colleges with bigger endowments and higher academic rankings were more likely to plan on testing than less resourced and lower-ranked institutions, and that private colleges were more likely to plan on testing than public institutions.

They also identified discrepancies in testing requirements by region. In comparing the five states for which they had the most data -- Massachusetts, New York, Pennsylvania, California and Texas -- they found that "states with the highest COVID-19 test positivity rate plan for the least amount of initial testing of students returning to campus."

“If you happen to go to a school with high visibility, you might get one kind of safety experience, whereas if you go to another kind of institution, on average you’re going to have another kind of safety experience,” Pachter said. “We thought that was very troubling.”

Pachter and his co-authors also found what they describe as “growing evidence that universities are using lax federal guidelines to justify the lack of testing on their campuses.” They specifically cited the University of North Carolina at Chapel Hill, which on Monday shifted to remote instruction for undergraduates and directed students to return home after 130 students and five employees tested positive for COVID a week into the semester. The university had opened for in-person classes against the advice of the local county public health director and despite vocal opposition from concerned faculty.

Chapel Hill did not require entry testing for returning students, saying on its website, “Testing every member of our community could create a false sense of security. The CDC does not recommend widespread, asymptomatic testing, and instead recommends that all individuals take preventative measures to reduce the spread of the COVID-19 virus. This is consistent with the advice of our own infectious disease and public health faculty experts.”

A recent study based on modeling found that colleges would need to test students every other day in order to keep the number of infections under control, and that testing only those students who showed symptoms of COVID-19 would not be sufficient to contain an outbreak. A. David Paltiel, the lead author of the study and a professor of public health at Yale School of Medicine, said symptom-based screening is inadequate because of the large number of asymptomatic cases and what he described as “the high likelihood of silent spreading.”

“You can’t play catch-up with this virus,” Paltiel said. “Schools that are responding only when students present to health services feeling sick are like fire departments that only respond to calls once there’s a report that the house has burned to the ground.”

Faculty at the University of Michigan at Ann Arbor published an open letter to university administrators and regents raising concerns about the adequacy of Michigan's testing plan and comparing it unfavorably to the testing-every-two-days model proposed in the Paltiel study.

Michigan's testing plans include testing undergraduates before they move into on-campus housing, diagnostic testing through student health services and surveillance testing of 3,000 to 3,500 students, faculty or staff per week who opt in for screening on a voluntary basis. (For context, Michigan’s enrollment exceeded 45,000 last fall.)

Dante Amidei, a professor of physics and an organizer of the open letter, described the surveillance testing approach as “inadequate compared to conclusions of publicly shared or published modeling and what other schools are doing.” He noted that "U-M has offered no countervailing analysis of the actual expected risk or outcome of their plan, and if they can't or won't show this, then they should not be reopening."

Michigan president Mark S. Schlissel and provost Susan M. Collins said in a universitywide message that "testing all students, faculty and staff on a twice a week basis would represent more than half the total number of tests currently being done in the entire state of Michigan."

"Right now, given our capacities to test, the reliability of the tests involved, I don’t want to have our tests take capacity away from our health system testing people who are sick, who need diagnoses. We don’t have the ability, nor do I think it’s necessary to test every student a couple of times a week," Schlissel said in a town hall meeting with faculty. "I bet you as the semester goes on our testing capacity will increase and we'll increase our surveillance testing … but I also think you’ll find out that other campuses who claim to be able to do this actually won’t be able to pull it off. Even the information load of tens of thousands of tests several times a week and the necessity to give feedback to people tested, deal with false positives, it's a very difficult thing."

Colleges that are planning for intensive testing of all students and in some cases employees include Harvard University, which is requiring students in campus housing to be tested three times a week; the Massachusetts Institute of Technology, which is requiring testing for students, faculty and staff one to two times every week depending on how frequently they are on campus; the University of Illinois at Urbana-Champaign, which is requiring twice-weekly testing of all faculty, students and staff on campus; and Yale University, which plans on twice-weekly testing for undergraduates and graduate students living in high-density graduate dorms and weekly testing for staff members who have "significant contact" with students.

The University of Wyoming is planning on twice-weekly testing of students and once-weekly testing of staff and faculty using an inexpensive test developed by researchers at Illinois; the per-test cost is $3.66, not including labor and equipment costs. The university is planning on processing tests in-house using its veterinary diagnostic laboratory and to have results within 24 hours to allow for prompt contact tracing and isolation of infected individuals.

Edward Seidel, Wyoming's new president as of July 1, was formerly the vice president for economic development and innovation at the University of Illinois, where he knew researchers had developed an aggressive testing plan.

"We began to consult with them, and meanwhile additional studies were coming out showing that you could really get into a runaway epidemic on campuses if you weren't able to nip this in the bud," he said. "We’ve seen evidence of this even in the last week or so."

"Our primary objective here is to provide the best college experience or the best education we can under the safest conditions that we can muster, and that’s why we’re going to this testing program," Seidel said.

In addition to testing students twice weekly using the UIUC-developed saliva-based test, the University of Wyoming will also test all students upon re-entry using a diagnostic test that costs more than $100 per test to administer.

Administrators estimate the testing program, which is being paid for with federal Coronavirus Aid, Relief and Economic Security (CARES) Act funds allocated by the state of Wyoming, will cost more than $2.05 million over the course of the fall.

William Schaffner, a professor of preventative medicine and a specialist in infectious diseases at Vanderbilt University's School of Medicine in Nashville, Tenn., said it is no surprise that testing plans vary given the wide range of institutions in terms of size, type and resources. Schaffner also said there are a variety of different opinions among public health experts about the efficacy of frequent testing of college students.

"First of all, regarding testing resources in the United States, they are limited," he said. "We don’t have the testing capacity we would like, and the testing capacity we would use often results in tests coming back quite late, so the question has come up -- 'Ought we to be dedicating so much of our testing capacity in the United States to healthy students who are not sick?'"

"I’m not sure I know what the best strategy is," Schaffner said. "I know that testing alone is not sufficient. You’ve got to do an awful lot of other things in order to control the virus. You’ve got to educate the population, in this case students. In our institution we’re doing testing on arrival, but all students have to be masked. We’re doing a lot of social distancing. We’ve rearranged the dormitory environment; we’ve looked at food services. We’re doing all sorts of things that will mitigate the impact of the virus, of which testing is an important but only one component. You can’t test your way out of COVID all by itself."

Public health experts also stress that testing has to be combined with a robust contact tracing initiative that identifies contacts of infected individuals and a plan to quarantine and isolate students. Taylor, of the American College Health Association, said colleges are generally mounting contact tracing initiatives either on their own or in collaboration with local public health offices and are setting aside housing for quarantine or isolation.

Whether the housing will be sufficient is another variable: at the time it announced plans to send students home, UNC Chapel Hill had just four empty rooms available for quarantining students.

Some colleges plan to tell students who test positive for COVID-19 to go home if they can, an approach Taylor said could make sense if the student lives relatively close to campus, has a stable family environment and no high-risk family members in the home, and is able to safely get there in a private vehicle without using public transit.

"There's no one right answer," Taylor said. "I know people are always looking for the one right answer, but different strategies are going to work well for different places" depending on such variables as their size, the prevalence of COVID and the characteristics of the residential population.

Erin Sauber-Schatz, a CDC official who leads a task force that provides guidance to colleges and other educational institutions, said the agency will continue to collect information about the efficacy of testing strategies.

"We're learning more and also looking at what different universities and schools are doing," she said. "We will look at the evidence around not only testing but also mitigation strategies. One of the things that CDC is looking to do is collaborate with different schools and universities to identify what is working and what is not working. Many of our recommendations right now are the mitigation strategies, things such as social distancing, wearing masks, hand hygiene, cleaning/disinfection. Those are the best tools that we have right now to help slow the spread of COVID-19."

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