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With significant variability across the United States in how university and college leaders approach campus testing for COVID-19, there are many questions that remain unanswered for forthcoming semesters. In this Higher Ed Careers interview, Kelly Cherwin asks Kirstie K. Danielson, Ph.D., epidemiologist and associate professor at the University of Illinois Chicago (UIC), some of our pressing questions regarding how campuses can and will navigate quickly approaching new semesters.
Kelly A. Cherwin (Director of Editorial Strategy at HigherEdJobs): What are some trends you have seen in regard to SARS-CoV-2 testing on college campuses? How and why should college campuses be testing? As an epidemiologist, do you foresee SARS-CoV-2 testing becoming a standardized part of admission to college campuses, like immunization verification is for many admission processes?
Kirstie K. Danielson: There is significant variability across the United States in how university and college leaders approach campus testing for SARS-CoV-2, both back when the fall 2020 semester started and still today. For example, at one end of the spectrum at the University of Illinois Urbana-Champaign, there was a mass campus effort at the beginning of the semester mandating testing for undergraduates twice per week, and other students and staff once per week. Implemented with good intentions, leadership anticipated that such a program would have a positive impact on COVID-19 rates. However, that didn’t pan out, as you may have seen with the university’s COVID-19 outbreaks reported in major media stories this fall, and may have instead offered a false sense of security. In comparison, you have at the other end of the spectrum, institutions such as Illinois State University just an hour’s drive away, with full in-person instruction but no mandated testing, that also saw outbreaks. In between there have been many other permutations of testing protocols tried at universities and colleges across the country. Here at the University of Illinois Chicago (UIC), where there are a very limited number of in-person courses this fall, we still have saliva-based testing available to anyone who is asymptomatic on a walk-in basis, and the diagnostic nasal swab testing is freely available for symptomatic students and staff. Fortunately, we have had few cases detected amongst our UIC staff and students this fall, but as is now occurring everywhere, rates are slowly rising. In light of this wide variation in institutional practices for testing, I want to highlight a critical issue. There is no central policy regarding testing from a federal, state, or local level, not even from the U.S. Department of Education or American Association of Universities, to guide decision-makers at higher education institutions. It has in essence become like the “Wild West,” with inconsistent practices limiting opportunities for scientific evaluations of best practices; and unfortunately leaving institutions open to the influence of financial or partisan interests instead of valuing and prioritizing the health and safety of students and staff.
With regard to why campuses should be testing for SARS-CoV-2, we know from recent statistical modeling published in the Journal of the American Medical Association, that the testing of students and staff at least every two days was the only scenario that was able to control the spread of the virus in the setting of in-person classes on a campus — even while still assuming optimum mitigation practices were being followed by students. Limiting testing to only symptomatic individuals was found to never be sufficient to control viral spread. Unfortunately, what cannot be accounted for in these models, nor even controlled in the real-world setting as we’ve found out, are the actions of young adults rebelling against testing and mitigation protocols, essentially subverting even the best and most well-intentioned efforts. What has happened on university and college campuses is a perfect storm arising from a long history of underfunded and under-staffed public health departments, the irrational partisan bent to COVID-19 undermining transparency, and the well-established risk behaviors of young, developing adults that any parent and teacher can attest to. Thus, what has been learned the hard way through these natural experiments on campuses, is that even the best, widespread testing efforts will not lower viral spread if in-person instruction and communal living arrangements are still occurring on campuses. In my opinion, the best model right now includes conducting the vast majority of classes virtually, with limited in-person courses for when it is most essential, PLUS widely and freely available testing for both symptomatic and asymptomatic individuals, PLUS mandating evidence-based effective practices of masking, social distancing, hygiene/cleaning, and contact tracing. In this case, UIC really stands out as an example of how universities can follow these protocols and still succeed for the students, education, and science. UIC decided last spring 2020 to conduct fall semester mostly virtual, which allowed faculty ample time to revamp their courses to teach remotely, and several IT and educational resources were made available to faculty to ease this challenging transition. Such intentional planning and support have made a world of difference for our students. Even testing every student to determine negative status prior to arriving on campus will not provide enough benefit, both now and over the next several years, simply due to the still less than perfect sensitivity of testing. It will only be the herd immunity established through wide-spread vaccination (possibly even required every year) that will allow for some normalcy to return to what we all remember and relish college life to be. Higher education leaders need to understand we are dealing with human beings, and young, still maturing individuals, not robots who will fall into line and strictly follow protocols.
An additional complex layer to testing on campuses is that campuses do not exist in a vacuum. They are dynamically involved in the local community, with students and staff constantly moving back and forth to live and commute for work and classes. Without such similar massive testing programs in the peripheral community, it raises serious doubts about the ultimate efficacy of such testing efforts just on campuses. In addition, it raises ethical questions as to how and why such precious resources as testing are prioritized and distributed across groups based on educational opportunities, economic status, and race/ethnicity. Therefore, university and college leaders must work closely with local community stakeholders to link testing resources across all populations. In addition, they must work together to create common messaging that it is everyone’s civic responsibility to practice simple low-cost, evidence-based mitigation practices (particularly in communal gathering places like dorms, fraternities/sororities, bars, and restaurants), otherwise it is simply wasted effort and money, and COVID-19 rates rise, as we have witnessed.
Cherwin: Many institutions (to name a few; University of Wisconsin-Madison, Illinois Tech, Harvard University, University of California Los Angeles) have dashboards that monitor testing and tracking of COVID-19 cases on campus. In your opinion, how and why are these dashboards useful? What information and statistics should institutions be including in these dashboards? The COVID-19 tracking at UIC is particularly transparent. What is UIC’s strategy and outlook for COVID-19 testing and tracking? What is your perspective on college campuses who are not testing their communities as transparently as UIC, and what repercussions can this have?
Danielson: UIC is one of many universities and colleges across the country that have developed systems to track the testing for and spread of the virus amongst its students and staff, and further, make these data fully available to the public via a dashboard website. UIC is the only public research university within the city of Chicago, and is one of the most economically and racially/ethnically diverse institutions in the country. This approach by leadership not only ensures transparency for local citizens, but helps instill public trust at a time when honesty from institutions traditionally considered elite or out of touch has been severely lacking. And of course, knowledge is power. The more we know about the spread of the virus in our UIC community, the better prepared we can all be to prevent and treat COVID-19 from a scientific and clinical perspective, and to also support each other emotionally in our day-to-day lives during these challenging and unprecedented times.
There is a rating system recently developed by academicians that continuously monitors and “grades” dashboards of universities and colleges across the country. Examples of factors that are considered essential to include, besides being updated daily, are data on both positive and negative test outcomes, data on students and staff separately, how many students are isolated/quarantined, test result turnaround time, and comparable data in the surrounding community. For example, UIC currently has a B+, slightly less than ideal because it still does not post comparable data of the surrounding city/county or test result turnaround time. I would argue that dashboards similar to UIC’s offer people transparency and knowledge about the current status of the virus in their communities. However, we should not be naïve. There must be open, rigorous public discussion and soul searching in regard to public and private institutions that persist in misrepresenting, or fail to fully disclose their data and rates, yielding to financial or political pressures. But for the most part, I still believe most institutions of higher education have the best interests of the public at heart and do this fully and willingly as good citizens of their communities.
Cherwin: Why is it important for campuses to have patient registries in response to COVID-19? In your opinion, what have departments of medicine on college campuses, like yours, learned from COVID-19 that they will take with them in the future?
Danielson: Data on basic statistics such as number of tests, number of positive/negative results, basic demographics of those tested, etc., are the core of the dashboard systems implemented by most universities and colleges. These are numbers needed by epidemiologists to study the virus and disease by person, place, and time. More in-depth data on disease risk factors and clinical outcomes, however, requires the ability to establish COVID-19 patient registries, which is more likely to occur at institutions that have medical and/or public health schools within their systems. This is particularly important in order to look at differences in the course of the disease across the U.S. by varying demographic, social, and clinical risk factors, and differences in disease clinical outcomes across treatments and by institution. Here at UIC, I have directed the UIC COVID-19 Registry for Research (UCRR) since April, which is meticulously documenting the clinical course and outcomes of COVID-19 patients in our hospital system. The impetus for it was the clinically significant need for such data, in direct response to the lack of a health data infrastructure at a national, state, and even local level. This is important to reemphasize: there is currently no common, reliable data collection platform for the diverse public health and medical departments across the country to compile and share data. Instead, we have the exact opposite. The dissociate spectrum of data collecting and reporting prohibit valid scientific comparison and analysis across populations in the U.S. Because of this, in the U.S., the robustness and timeliness of our medical research often lags behind that of other countries which have a unified, widely available medical data infrastructure. In the U.S., instead we need to rely on human resources to manually extract, or computer programming to search for the data we need. These are incredibly time-consuming and costly processes. For example, within our UIC hospital system this summer/fall, the electronic medical record system was changed to a new software during the pandemic, adding an additional layer of complexity to gathering data on patients. Further, our goal to compare apples-to-apples data from other Chicago medical institutions exponentially increases the necessary work to do this kind of research. Unfortunately, due to decades of partisan financial interests’ disregard for our Public Health System at high levels in our government, these are the archaic forms of data collection for epidemiological and clinical research relegated to us right now.
But even with all the significant day-to-day and system-wide challenges, the individuals and health care providers on the front lines of this pandemic at medical institutions across the country deserve an enormous amount of our gratitude. From a clinical perspective, they have synthesized the clinical evidence emerging day-to-day, adjusted their clinical approaches to attain better outcomes, and openly shared these data with their colleagues and students. These are experiences that will forever change the care given to patients from the most senior to the most junior students in medicine. Simply put, there has been a paradigm shift in clinical practice and research, and it will never look the same again here in the U.S. and globally, very similar to what happened with HIV/AIDS decades ago.
Cherwin: Please briefly describe your research interests. Do you think your research will be affected or change due to COVID-19?
Danielson: My training and expertise are in the area of type 1 diabetes (historically called insulin-dependent or juvenile diabetes). Specifically, I am an epidemiologist who investigates complications of type 1 diabetes, and therapies for establishing better glucose management in the disease. I have decades of experience working with and analyzing data from longitudinal registries of individuals with diabetes. At UIC, I directed the development of the largest cohort registry of data on individuals receiving islet cell transplant as a potential functional cure for type 1 diabetes, based on the clinical trials here at UIC. Thus, I am now extending this expertise to overseeing a cohort registry of inpatients with COVID-19 at our institution. Ultimately, as epidemiologists, our unifying goal is to use these large datasets to describe risk factors for and outcomes of diseases across varying characteristics of people, changes over time in treatments, and differences by where people live and work. These skills can be applied to chronic diseases such as diabetes, and of course infectious diseases such as COVID-19. And we do this in order to inform and enhance prevention efforts and therapies.
As I mentioned earlier, the state of clinical medicine not only in the U.S. but globally has forever been changed. This is also the case for epidemiologic and biomedical research. Similar to generations before us, where lives were demarcated by pre/post-Depression, -WWII, or -Vietnam, such is the case for the current generation of those in medicine and public health for pre/post-COVID-19. Education, research, clinical care, and career trajectories will all be changed for better or worse due to this pandemic. As a personal example, conducting human subjects research in-person has become nearly impossible, so as to not risk the health of the people we want to study and help. Therefore, human subjects research, at least in-person, will ultimately be delayed until vaccinations have established herd immunity. Researchers are left to study existing data, or data accruing from electronic medical records. This is not to say those data are not important, but one leg of our research “stool” has been severed leaving the future trajectory of our research unstable. Fortunately, funding agencies such as NIH and various foundations acknowledge these significant challenges for research right now, but our biomedical and public health research will not fully recover for years to come.