Abstract
The coronavirus disease 2019 (COVID-19) pandemic poses an existential threat to many US residential colleges; either they open their doors to students in September or they risk serious financial consequences. To define severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening performance standards that would permit the safe return of students to US residential college campuses for the fall 2020 semester. This analytic modeling study included a hypothetical cohort of 4990 students without SARS-CoV-2 infection and 10 with undetected, asymptomatic SARS-CoV-2 infection at the start of the semester. The decision and cost-effectiveness analyses were linked to a compartmental epidemic model to evaluate symptom-based screening and tests of varying frequency (ie, every 1, 2, 3, and 7 days), sensitivity (ie, 70%-99%), specificity (ie, 98%-99.7%), and cost (ie, $10/test-$50/test). Reproductive numbers (Rt) were 1.5, 2.5, and 3.5, defining 3 epidemic scenarios, with additional infections imported via exogenous shocks. The model assumed a symptomatic case fatality risk of 0.05% and a 30% probability that infection would eventually lead to observable COVID-19-defining symptoms in the cohort. Model projections were for an 80-day, abbreviated fall 2020 semester. This study adhered to US government guidance for parameterization data. Cumulative tests, infections, and costs; daily isolation dormitory census; incremental cost-effectiveness; and budget impact. At the start of the semester, the hypothetical cohort of 5000 students included 4990 (99.8%) with no SARS-CoV-2 infection and 10 (0.2%) with SARS-CoV-2 infection. Assuming an Rt of 2.5 and daily screening with 70% sensitivity, a test with 98% specificity yielded 162 cumulative student infections and a mean isolation dormitory daily census of 116, with 21 students (18%) with true-positive results. Screening every 2 days resulted in 243 cumulative infections and a mean daily isolation census of 76, with 28 students (37%) with true-positive results. Screening every 7 days resulted in 1840 cumulative infections and a mean daily isolation census of 121 students, with 108 students (90%) with true-positive results. Across all scenarios, test frequency was more strongly associated with cumulative infection than test sensitivity. This model did not identify symptom-based screening alone as sufficient to contain an outbreak under any of the scenarios we considered. Cost-effectiveness analysis selected screening with a test with 70% sensitivity every 2, 1, or 7 days as the preferred strategy for an Rt of 2.5, 3.5, or 1.5, respectively, implying screening costs of $470, $910, or $120, respectively, per student per semester. In this analytic modeling study, screening every 2 days using a rapid, inexpensive, and even poorly sensitive (>70%) test, coupled with strict behavioral interventions to keep Rt less than 2.5, is estimated to maintain a controllable number of COVID-19 infections and permit the safe return of students to campus.
Highlights
Universities across the United States are struggling with the question of whether and how to reopen for the fall 2020 semester.[1,2] Residential colleges, with communal living arrangements, shared dining spaces, intimate classrooms, and a population of young adults anxious to socialize, pose a particular challenge
Cost-effectiveness analysis selected screening with a test with 70% sensitivity every 2, 1, or 7 days as the preferred strategy for an Reproductive numbers (Rt) of 2.5, 3.5, or 1.5, respectively, implying screening costs of $470, $910, or $120, respectively, per student per semester
After a new coronavirus disease 2019 (COVID-19) case is detected, further questions emerge regarding how to conduct subsequent tracing; how to isolate detected cases in the context of congregate housing arrangements; and how to protect other at-risk populations, including faculty, staff, and members of the surrounding community.[5]. These uncertainties underscore the pressing need for both a generalized assessment of population-wide screening for SARS-CoV-2 and a comprehensive plan for reopening universities
Summary
Universities across the United States are struggling with the question of whether and how to reopen for the fall 2020 semester.[1,2] Residential colleges, with communal living arrangements, shared dining spaces, intimate classrooms, and a population of young adults anxious to socialize, pose a particular challenge. In the absence of an effective vaccine, a proven therapy, and/or sufficient herd immunity, the best hope for reopening campuses in the fall is likely to be a robust strategy of behavior-based prevention combined with regular monitoring to rapidly detect, isolate, and contain new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections when they occur.[3]. After a new coronavirus disease 2019 (COVID-19) case is detected, further questions emerge regarding how to conduct subsequent tracing; how to isolate detected cases in the context of congregate housing arrangements; and how to protect other at-risk populations, including faculty, staff, and members of the surrounding community.[5] These uncertainties underscore the pressing need for both a generalized assessment of population-wide screening for SARS-CoV-2 and a comprehensive plan for reopening universities
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