In April in the early weeks of the pandemic, as University of Missouri President Mun Choi evaluated whether his school should come back in the fall, he predicted that 20 students on his campus would need to be sequestered with COVID-19 if they came back for in-person classes.
Upon reopening in August, Missouri had isolation and quarantine housing available for more than 200 students. By Thanksgiving, the school had more than 2,300 reported cases overall.
As students prepared to return to the University of Illinois, officials forecast 700 positive cases by Thanksgiving break.
That number hit almost 4,000 by the holiday.
Many colleges and universities throughout the country didn’t try to reopen this fall. At those that did, a wide range of policies and protections were put in place in hopes of limiting the spread of the virus.
But an analysis of the efforts at four major Midwestern universities shows that no matter what schools tried — whether it was Illinois’ much-touted testing program or Missouri’s lack of comprehensive or random testing — the results were much worse than predicted. At those campuses and the flagship universities in Indiana and Wisconsin, at least 15,000 tested positive for COVID-19 this fall.
In reopening, campuses were facing unprecedented challenges.
“This was the most complex mobilization and repurposing of resources for the common mission since World War II,” said Kirk White, co-chair of the COVID Response Unit at Indiana University-Bloomington.
But, White said, universities aren’t built for 90-degree turns: Their policies and procedures are fortified through years of repetition.
As a result, college students were part of a mass experiment as they came back to campus for socially distant in-person learning. The outbreaks began immediately in the fall, before classes even started. Case numbers soared into the thousands less than a month into the semester. Universities struggled to find places to house sick students and fully investigate their close contacts — mitigation strategies that are key to squashing an outbreak.
COVID-19 superspreaders such as bars and Greek housing were hard to control, becoming hotspots for college towns.
And it wasn’t just the students who got sick. After campus cases spiked, cases in the surrounding communities rose along with deaths, suggesting sick students in part fueled mass community spread. The Centers for Disease Control and Prevention released a study at the beginning of this month that concluded counties with large universities that had in-person instruction saw a 56% increase in COVID-19 cases, whereas those with remote instruction saw a decrease. As cases across the nation declined overall in August, cases spiked among 18-22 year olds, which is usually followed by an increase in cases among those 60 and older.
But a combination of students ignoring reporting mandates and insufficient testing and contact tracing efforts from schools masks the real impact. Coupled with a lack of consistency in data collection from campus to campus and county to county, the end result is that the pandemic’s true impact in college towns will never be known.
Testing varied widely
One key way to measure the impact of in-person reopenings would be to look at metrics like case numbers and positivity rates, which reflect not just how much disease there is but how much testing is being done.
But different schools adopted different testing procedures, making comparisons misleading. For example, Missouri had the most minimal testing policy of the four schools — and the least accessible testing program — and it shows the fewest number of cases per capita. One expert estimates that as many as 10,000 cases could have gone undetected at Missouri, where enrollment was about 31,000.
Some schools conducted entry testing as students returned to campus to catch cases before they spread into the community. Others took a surveillance approach, where they consistently tested portions of the student body to detect asymptomatic cases.
At the University of Wisconsin’s flagship campus in Madison, with an enrollment of about 45,000, students and faculty could get tested at any time and didn’t have to show symptoms to get one. Visits to testing facilities were free and unlimited.
From the start, the number of cases was staggering. During student move-in, Aug. 25-31, there were 96 student cases. Fast forward to Sept. 10, and there were more than 1,000 student cases.
Testing reached a high of 2,200 tests per day during that time frame. In total, there were 5,165 confirmed cases by the university, as reported on its dashboard near the end of the fall semester.
Indiana University-Bloomington students were also subject to on-arrival entry testing. Of the almost 34,000 entry tests administered, 346 — around 1% — came back positive. The school has about 43,000 students.
Throughout the semester, Indiana offered testing to any student, faculty or staff member who experienced symptoms. One of the pillars of its response was asymptomatic testing, said the man overseeing the effort, Aaron Carroll.
For most of the semester, the university had the capacity to process about 10,000 tests a week. Each week, Carroll’s team selected a random sample of students, faculty and staff members for surveillance testing. They also targeted specific dorms or Greek houses where he knew the disease was present.
In total, the school reported about 3,800 positive tests out of a total of over 146,000 tests administered before Thanksgiving break. The university’s dashboard does not report the number of individual cases, but according to Carroll, “for the most part, positive tests equal cases.”
“I think our response is about as robust as anyone,” Carroll said, adding one exception: “U of I has done more testing than anyone else. Period.”
Illinois and Missouri — polar opposites
At the University of Illinois at Urbana-Champaign, with about 50,100 students, undergraduate students got twice-weekly testing while faculty, staff and graduate students were tested once a week. It introduced an expansive saliva testing program, called SHIELD T3, which allowed for rapid processing of results.
But more robust testing didn’t mean that Illinois’ spread was controlled.
The university recorded more than 4,500 cases as of Dec. 17, with the spread peaking in the initial weeks after students returned to campus. The university had recorded more than 2,000 cases by Sept. 16, less than a month after students returned.
Yet simply tracking numbers can be misleading.
Though it’s impossible for the total number of cases to be fully known at any university, those schools that had some form of surveillance testing have a clearer and more accurate picture of the number of cases they had on campus.
Missouri, unlike Illinois, Indiana and Wisconsin, did not have any form of surveillance or entry testing — sticking to only testing symptomatic students and their close contacts.
When developing testing protocols prior to students returning, Missouri did consider implementing some form of mandatory testing but opted out — concluding “the same as the CDC: Mandatory mass testing is not recommended,” according to the Show Me Renewal plan that outlines the university’s COVID-19 policies.
However, the CDC does recommend surveillance testing.
In its testing guidance for institutions of higher education, the CDC says that “a strategy of entry screening combined with regular serial testing might prevent or reduce SARS-CoV-2 transmission.”
Missouri stands out for its testing model for another reason: Students were required by the county to have a doctor’s referral.
Ana Bento, an assistant professor in epidemiology and biostatistics at Indiana University’s School of Public Health, has been studying COVID-19 on college campuses and what mitigation strategies are most effective at reducing cases.
And while no single mitigation strategy is the silver bullet, Bento said one key strategy is among the most positive and efficient: testing.
By only testing symptomatic people, about 50-60% of infections go without being detected because most infections occur with people who are asymptomatic or will develop symptoms in the next few days, Bento said.
“Ideally, … testing everyone as often as possible even if they do not have symptoms is paramount,” she said. “Precisely because most infection events occur with individuals that have no clue they are infectious."
Roy Parker, a professor of biochemistry at the University of Colorado Boulder, conducted research that had similar findings. He co-authored a paper with the Harvard T.H. Chan School of Public Health that examined how surveillance testing would reduce COVID-19 cases.
His study found that the sensitivity of the COVID-19 tests — how little of the virus they can detect — is not as important as frequently testing people and getting the results back quickly. The study found that testing frequency was the primary driver of population-level epidemic control when compared with testing sensitivity or even result turnaround times.
Parker said that people are most infectious, or most likely to spread the virus, right before they develop symptoms, also known as being presymptomatic.
By only testing symptomatic people, Parker estimated that possibly between 5,000 and 10,000 cases went undetected at Missouri. He said that easily a third of the student population, which is about 31,000 students, could have been infected over the semester.
"Individuals tend to have the same behavior in most places across the country,” he said. “So I think (Illinois) probably had a similar number of cases, they might just have found more of them."
At Missouri, students were required to log their symptoms daily via the #CampusClear app, which provided the university “with a high-level overview of community health,” according to the Show Me Renewal plan.
Back in August, the Office of the Chancellor sent out an email saying that the app would grant students access to various locations across campus. If they didn’t record any symptoms, they would be given the all clear. If a student didn’t have the app, they would be screened and have their temperature taken prior to entering.
But Missouri didn’t start requiring students to show their “Good to Go!” screens until Oct. 19, when there were only 68 active student cases on campus — well after the September surge.
While Illinois received plenty of national praise for its testing system, there was a vocal minority of students who disagreed with the university’s reopening. On Oct. 16, People Over Profit organized a protest on the quad with roughly two dozen student demonstrators. The protest lasted for about an hour and concluded with a “die-in” in which all the protestors laid on the ground in silence.
“All I’ve heard since the beginning of this pandemic is excuses,” one protestor said through a megaphone. “Excuses from these institutions, excuses from the supposed leaders who are protecting the system that continue to work as it was designed. The University of Illinois is no different than any other institution that exploits students for mass profiteering.”
Up until Aug. 24, the first day of classes at Indiana, Monroe County — home to the university’s flagship campus in Bloomington — had reported about 950 cases of COVID-19. As of Nov. 18, the total was just over 4,800.
However, the semester coincided with an exponential surge in cases statewide.
Carroll, director of Surveillance and Mitigation Testing for Indiana University, said there was little evidence that the university posed a danger to the rest of the community, referencing relatively low prevalence rates on campus even as case numbers surged in surrounding areas.
“Given that the state had monstrous exponential growth starting in October, and we did not, I think that makes a pretty solid case that we made a reasonable bubble,” he said.
At the time of the interview, Indiana ranked third among all U.S. states for cases per 100,000 and seventh in total cases.
In Dane County, Wisconsin, the day before students moved in on Aug. 25, the total case count was 5,163. By Thanksgiving break, cases were more than four times higher with a total of 23,626.
Wisconsin student cases mimicked the county’s peaks and lulls with a surge in September after students returned and a second wave in mid-November. Statewide, cases began rising in early September and continued to steadily climb until mid-November.
Aside from the initial September surge, 18-to-24-year-olds consistently had among the lowest weekly case counts out of all other age groups in Wisconsin aside from those younger than 18. Dane County overall had the third highest case numbers in the state as of the end of December.
In Boone County, — where Missouri has its main campus —prior to students’ return Aug. 12 for move-in, the county had 1,462 total cases. By Thanksgiving break, it had more than 9,800 total cases.
Cases throughout Missouri steadily rose during the fall, surging in late October and falling off in early December — similar to Boone County. The only exception is the massive spike in cases the county saw in late August and early September.
Boone County ranked higher than St. Louis, Kansas City and Greene County for cases per 100,000, according to the state’s COVID-19 dashboard, all of which are home to multiple universities and colleges just like Boone County.
Determining how community spread was impacted by students returning to campus is hard to know, but there is little argument that student cases contributed to rising cases in their respective counties.
Scott Clardy, assistant director of the Columbia/Boone County Public Health and Human Services Department in Missouri, said COVID-19 cases saw a significant increase after students returned, with 18-to-22-year-olds making up over a quarter of the county’s total cases.
"I don't mean to blame the students or Mizzou or anybody,” he said. “But when you bring 30,000 new people into a community from outside the community, that type of thing is going to happen."
Bento, from Indiana, found in her research that regardless of whether a university offered in-person or a hybrid of online and in-person classes, students would return to campus in the same numbers as if classes were solely in-person.
While offering a hybrid model is meant to keep the number of students on campus and physically in classrooms lower, it brings the same number of students back into the community.
According to Bento and her research, the majority of COVID-19 spread isn’t happening in classrooms.
“It's actually post-class time when students go back to their houses or their dorms and where ... people relax a little bit, and they let their guard down,” she said. “And then that's where situations that allow for transmission events to occur happen."
Looking back at the semester, Carroll from Indiana feels pretty good about the story the numbers tell.
“At the beginning, we sort of had an outbreak,” he said. “But then we drove things into the ground, and our prevalences were pretty low throughout most of the semester even as the rest of Indiana raged. I would say that’s a win.”
Late semester relief
As Wisconsin went into Thanksgiving break, it left behind a trail of more questions than answers about its response.
Matthew Mitnick, chair of the student government, believed that the administration could have done a better job at communicating.
“There is so much disinformation, and the communication has been a nightmare,” Mitnick said. “They have not done a great job at messaging out to students, and they themselves do not know the policies half the time.”
Katie McGlassen attributes the problems with Wisconsin’s response to a lack of student input in the plans for reopening. The university’s vice chancellor of affairs is trying to remedy the situation by forming a student committee to give input so that the spring semester goes better.
For Missouri, the only truly different part of its COVID-19 mitigation plan was the lack of surveillance testing. But Clardy said he didn’t think it needed to have surveillance testing because other universities, like Illinois, didn’t end up better off than Missouri.
"I can't really fault them with any of the decisions that they've made,” he said. “They've been extremely careful about how to conduct classes and, just in general, events that occur on the Mizzou campus outside of even academics."
As increased community cases stressed hospitals and contact tracing, some universities pulled the plug and decided to move completely online after Thanksgiving, while others had already decided to do so prior to the semester starting.
Clardy was relieved when Missouri made the call.
“I was concerned we could end up with a big jump in cases,” Clardy said, “like what we saw when they came here to begin with.”
Despite Missouri’s consistent messaging throughout the fall that surveillance testing is not necessary, the university announced Dec. 22 that all students living in campus housing would be subject to entry testing prior to beginning spring courses. Testing is available for students living off campus, but it’s not required.
Throughout the last four months, a lot of emphasis has been placed on students and their individual responsibility to prevent the spread of COVID-19.
But Parker, of the University of Colorado Boulder, said that universities also have a responsibility to protect their students and communities.
"Universities have an obligation, if they can, to try to keep their communities COVID-free, both to protect the students and give them the best learning environment,” he said.
Reporters Gavin Good , Julia Morrison and Dylan Tiger from the University of Illinois, Hali Tauxe from the Indiana University and Danielle DuClos and Chris Martucci from the University of Missouri contributed to this story.