Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 - Holmes Murphy

 
DECEMBER 29, 2020

ACHA Guidelines
Considerations for Reopening Institutions of
Higher Education for the Spring Semester 2021
     n seven months since the May 7, 2020, release of the      • United leadership is critical to a sustained and

I    ACHA Guidelines: Considerations for Reopening
     Institutions of Higher Education in the COVID-19
     Era, unprecedented research, diagnostic testing,
vaccine, and treatment developments have advanced our
                                                                 effective response. The leadership must have accurate
                                                                 and reliable data, a clear understanding of crisis
                                                                 management, and an in-depth knowledge of
                                                                 policies/procedures. They must leverage the research
approach to SARS-CoV-2, the novel coronavirus that               enterprise and campus and local experts and gain the
causes COVID-19. For many campuses, the short-term               trust and respect of the campus community through
goal upon entering the fall semester was to reach                honesty, clear communication, transparency, and
Thanksgiving break and provide a safe environment to             concern for the overall health and well-being of the
carry out the institution’s academic, research, and service      campus and its surrounding community.
missions; adhere to public health guidance; meet the
                                                               • Multilayered mitigation strategies with universal
expectations of students, faculty, and staff; and avoid
                                                                 masking, physical distancing of 6 feet or more, and
fatalities. At the time of this writing, the nation is deep
                                                                 good hand hygiene accompanied by a coordinated
within a third wave of the pandemic and breaking daily
                                                                 public health strategy of robust testing, contact
records for confirmed cases, hospitalizations, and deaths.
                                                                 tracing, and expeditious isolation and quarantine
The emergency use authorization of two safe and effective
                                                                 processes are the most effective measures for
COVID-19 vaccines is bringing new hope at the end of an
                                                                 decreasing the risk of transmission of SARS-CoV-2.
arduous semester and calendar year.
                                                               • Most campus outbreaks have been related to small
After several months of experience, research, and practical
                                                                 and large gatherings without masking and without
applications, we know more, have learned from early
                                                                 physical distancing that have occurred in bars, in on-
missteps, and are better prepared for spring semester. For
                                                                 and off-campus residences, and in Greek housing.
months, institutions of higher education (IHEs) have been
in perpetual motion to retrofit facilities; acquire personal   • Managing a campus outbreak requires a coordinated
protective equipment (PPE) and cleaning supplies; educate        response and a close partnership among state and
and train the campus community; implement technology             local public health authorities, community leaders
and testing programs; transition to telemedicine and             and the IHE’s COVID-19 emergency response team.
telemental health services; and create new processes,            Identifying key indicators and triggers to implement a
systems, and partnerships to address the pandemic. This          change in campus operations should be established
document serves to provide updated considerations and            early, widely communicated, and continuously
guidance for IHE presidents and chancellors, senior              monitored. The health services director or designee
leaders, and college health professionals to inform their        should play an integral role in this effort.
planning for the upcoming semester.                            • Students with COVID-19 are frequently
                                                                 asymptomatic. Preventing transmission by
Lessons Learned                                                  asymptomatic and presymptomatic individuals
 • Planning and preparation, including contingency               requires universal masking, physical distancing, swift
   plans are essential for an organized, effective, and          identification through testing and contact tracing; and
   timely response. The response must include strategies         isolation and quarantine.
   for recovery and future preparedness. Flexibility and
   quick adaptation to the changing environment are
   critical for success.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 2

• SARS-CoV-2 is primarily transmitted via                       staff, physical therapists, equipment staff, and
  aerosols/droplets; therefore, proper physical distance        officials. In the “Appendix, Sport Transmission Risk,
  among people in classrooms, along with appropriate            Sample Testing, and Masking Strategies” to its
  ventilation and universal mask requirements will              Resocialization of Collegiate Sport: Developing
  minimize transmission in instructional settings.              Standards for Practice and Competition, Second
                                                                Edition (Updated), the NCAA provides details of
• There is little evidence to show secondary
                                                                testing recommendations.
  transmission is occurring either student-to-student or
  student-to-faculty member in instructional settings
  where everyone is wearing masks and proper               The Work Force
  physical distancing is maintained.                       Since the release of ACHA’s Reopening Guidelines in
• Though fomites and surfaces pose a lesser threat,        May 2020, CDC has continued to update and expand the
  high touch areas must be cleaned and disinfected         list of conditions that place individuals at increased risk of
  regularly, and all must practice meticulous hand         severe illness if infected with SARS-CoV-2 and has also
  hygiene and avoid self-contamination with unwashed       developed a list of conditions that might place individuals
  hands.                                                   at increased risk (see both lists here). Campus human
                                                           resources (HR) leadership should continue to monitor
• Student adherence to public health practices and the     these conditions and evaluate and modify policies and
  campus COVID-19 plan is essential for success.           accommodations based on updated CDC guidance.
• Students must be involved in planning, messaging,        Faculty and staff, particularly those on the front line
  and the development of safer social activities.          providing in-person services/instruction, must have ample
• Fostering healthy behaviors requires a social norming    and appropriate personal protective equipment (PPE) and
  approach and the use of all available channels of        cleaning and sanitizing materials available.
  communication including social media, texts, and         The pandemic-fueled economic downturn, social isolation,
  email.                                                   and “Zoom fatigue” have exacerbated stress levels,
• The frequency of testing and rapidity of turnaround      anxiety, and burnout, particularly in health, counseling,
  time are more important than the sensitivity of the      and health promotion staff and those faculty and staff who
  test. Surveillance, screening, and diagnostic testing    have shouldered the front-facing, day-to-day activities of
  strategies are all important in reducing the spread of   the in-person campus. At a minimum, the IHE should
  COVID-19 on college campuses.                            ensure all faculty and staff have access to employee
                                                           assistance programs and other wellness resources.
• Because of the numerous unknowns, the rapidly
  evolving nature of the pandemic, and the inability to    Considerations for the work force:
  predict student behavior, IHEs have established            • Update COVID-19 safety educational and training
  surveillance systems and thresholds to quickly               materials to include new campus policies, new
  change course. Planning must account for different           isolation/quarantine durations, revised definitions and
  scenarios and exit strategies.                               reminders to wear masks, maintain physical distance,
• Herd immunity will only be achieved with delivery            practice good hand hygiene, clean and sanitize, and
  and widespread public acceptance of a safe and               to promote vaccine adherence to influenza and the
  effective vaccine.                                           COVID-19 vaccine.
• Recognition of the mental health effects on the            • Have faculty, staff, and students review the updated
  campus community cannot be minimized. The                    educational and training materials in a timely
  emotional impact of loss, uncertainty, isolation, and        manner, ideally within the first two weeks of return
  quarantine have been notable.                                to campus.
• The NCAA has continued to revise their                     • Review and update HR policies and employee
  recommended testing strategy for each sport. Testing         accommodations based on current CDC guidance.
  is important in all intercollegiate sports, with the       • Develop plans for alternative work assignments for
  frequency and timing determined by the sport’s risk          high-risk staff.
  level. Testing strategies should include, at a
  minimum, all “Tier 1” individuals, which includes          • Develop employee health program protocols for
  student athletes, coaches, athletic trainers, medical        management of exposed and ill staff members.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 3

 • Develop return to work protocols for staff who have         • Screen all patients and staff for COVID-19 symptoms
   become ill or exposed to COVID-19.                            before entering the clinic. Temperature checks may
                                                                 also be considered.
 • Strongly encourage both flu vaccination and COVID-
   19 vaccination (when available). Consider                   • Develop a plan for students with respiratory
   implementing a requirement for active declination of          symptoms who need transportation to SHS, housing,
   both.                                                         or local hospitals. Ensure after-hours care options are
                                                                 included.
 • Address faculty/staff mental wellness and provide
   resources such as employee assistance programs,             • Incorporate telehealth options as well as in-person
   financial literacy information, mindfulness teachings,        visits into triage protocols.
   and “care for the caregiver” programs.
                                                               • Continue to utilize telemedicine visits and provide
 • Provide coaches and mentors and/or workshops to               students with options for telemedicine or telephone
   assist faculty with technology and innovative                 consults when appropriate. Students with conditions
   instruction tools.                                            placing them at higher risk for complications from
                                                                 COVID-19 should be encouraged to seek care via
 • Continue daily symptom checking and reinforce
                                                                 telemedicine.
   messages to stay home or leave work if sick.
                                                               • Develop protocols for in-person visits. Consider
Student Health Services (SHS)                                    designating and scheduling providers for
                                                                 telemedicine and in-person visits on a daily basis.
The role of student health services was expanded during          Allocate a separate area of the clinic for acute illness.
the pandemic, often with SHS staff adding testing, contact
tracing, and case management to their responsibilities.        • Update screening forms to incorporate COVID-19
Campuses will continue to look to student health services        symptoms, including but not limited to: fever, cough,
for medical and public health expertise, and SHS                 shortness of breath, chills, muscle pain, headache,
leadership should be poised to deliver current, sound,           sore throat, congestion, nausea, vomiting, diarrhea,
evidence-informed recommendations. Maintaining                   anosmia, and dysgeusia.
essential services to students while providing pandemic-       • Continue the delivery of routine clinical preventive
related care and campus support have challenged and              services when at all possible to prevent health
strained the campus health system.                               consequences of delayed care.

Patient Care Considerations                                    • Ensure protocols for managing patients with acute
                                                                 respiratory symptoms include masking the patient,
In concert with the recommendations outlined in the May          quickly rooming the patient, limiting and tracking the
2020 ACHA Guidelines: Considerations for Reopening               number of staff who enter the room, limiting the
Institutions of Higher Education in the COVID-19 Era, the        movement of the patient throughout the SHS, and
SHS should:                                                      cleaning of spaces where the patient was present.
 • Advise patients to call before coming to the SHS for        • Avoid use of nebulizers and peak flow measurements
   any type of visit.                                            which can generate additional aerosols.
 • If possible, utilize an online or telephone process for     • Ensure a COVID-19 testing plan is in place for
   patient check-in.                                             students, faculty, and staff, either on- or off-site.
 • Limit student contact with SHS computers/keypads.             Frequency and type of testing may vary depending on
   Have students complete and submit forms (health               community and campus resources.
   history, immunizations, consents, etc.) in the patient      • If dental operations are within the scope of services,
   portal or utilize EMR templates.                              review updated CDC Guidance for Dental Settings.
 • Require all patients to wear face masks (or cloth face      • Work closely with the marketing and
   coverings if adequate face masks are not available).          communications department to continue to provide
 • Prohibit visitors, children, or accompanying guests           updated messaging about COVID-19 protocols,
   who are not receiving care or services from entering          policies, and services. Use a variety of platforms
   the facility.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 4

                                                               • Ensure adequate PPE is available and that all staff are
    including websites, social media, and signage.
                                                                 trained in its use. Monitor staff compliance with PPE
    Involve as many campus entities as possible in
                                                                 use. Enough PPE supplies should be stocked to meet
    communicating these messages (housing, dining,
                                                                 both patient care and testing needs.
    recreation, etc.).
                                                               • Maintain situational awareness of COVID-19 in the
 • Work closely with residential life staff to identify and
                                                                 state, city, and on campus.
   manage students who require isolation or quarantine.
                                                               • Consider a mandatory COVID-19 testing policy for
 • Develop relationships and agreements with local
                                                                 all staff.
   emergency departments (ED) to accept ill patients
   requiring a higher level of care.                           • Implement effective patient-centered policies to
                                                                 safely meet the health and counseling needs of
SHS Facility Considerations                                      students.
 • Design facility layout to provide in-person clinical        • Develop employee health program protocols for
   services for needed preventative care and care for            management of exposed and ill staff members.
   illnesses/injuries other than COVID-19 in the safest          Develop return to work protocols for staff who have
   manner possible while minimizing transmission of              become ill or exposed to COVID-19.
   COVID-19.
                                                               • Document all providers and support staff involved in
 • Segregate waiting areas for ill and well patient visits.      the care of every patient so that exposures can be
   If separate waiting rooms are not available, consider         tracked.
   placing a tent outside or identifying a satellite space
                                                               • Ensure staff are knowledgeable about COVID-19
   for patients with respiratory symptoms. Deploy
                                                                 symptoms, transmission, relevant protocols, and
   signage providing clear guidance on how to proceed.
                                                                 updated CDC guidance.
 • Perform COVID-19 testing outdoors when possible.
                                                               • Develop plans for alternative work assignments for
 • Reconfigure all waiting and other clinic areas to             high-risk staff.
   promote physical distancing.
                                                               • Continue to track costs and funding mechanisms for
 • Ensure adequate amounts of alcohol-based (at least            testing, contact tracing, and case management.
   60%) hand sanitizer, face masks (or cloth coverings if        Consider the financial impact of mass vaccination
   masks are not available), tissues, and closed bins for        with COVID-19 vaccine.
   disposal are available.
                                                               • Develop plans for mass immunization with COVID-
 • Provide plexiglass/clear barriers between reception           19 vaccine, including necessary personnel, supplies,
   staff and waiting areas.                                      and locations for vaccination administration and
                                                                 delivery.
 • Develop protocols for environmental management,
   including frequency and responsibility for clinic           • Identify appropriate charges (if indicated) for visits,
   cleaning and decontamination.                                 telehealth services, testing, and supplies, including
                                                                 medications or vaccines. Identify correct billing
 • Assess air exchange of care, treatment, and
                                                                 codes to facilitate prompt, accurate reimbursement if
   administrative spaces and determine time required
                                                                 billed to insurance.
   between uses in the event of a known or suspected
   COVID-19 patient.
                                                              Mental Health
 • Ensure adequate IT network, wi-fi, hardware, and
   expertise to support telemedicine and telemental           Addressing the mental health and wellness needs of our
   health visits.                                             students and campus community has proven to be a tall
                                                              order for college health and counseling centers and
SHS Administrative/Staff Considerations                       campuses at large throughout the pandemic. Even before
                                                              the pandemic, college and university presidents placed
 • Utilize patient satisfaction surveys to obtain feedback    student mental health needs at a high priority. College
   about telemedicine or phone visits as well as clinic       counseling centers moved quickly to develop new
   services. Develop a system to review the quality of        platforms for providing services, forge new campus and
   care provided and incorporate into existing peer
   review processes.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 5

community partnerships, and establish a diverse array of         Technology and Telemental Health
services using hybrid and fully virtual venues to support
                                                                 In spring 2020, most college health and counseling centers
student mental health and wellness through these difficult
                                                                 pivoted to virtual platforms, establishing eligibility and
times.
                                                                 exclusion criteria and practice guidelines for the provision
JED’s Comprehensive Approach identifies key areas that           of telemental health services. Counseling centers will
colleges should address to support student mental health         likely continue to refine, expand, and deliver their services
and to limit substance misuse and suicide. Within each           in this manner throughout the upcoming spring semester.
strategic area, there are multiple activities and efforts that   Widespread temporary state-by-state exemptions helped
colleges can implement to support student mental health.         address legal barriers that prevented counseling across
The Jed Foundation emphasizes that a campus-wide                 state lines. The sustainability of telemental health services
systemic approach is integral in efforts to prioritize the       will be based on evaluative outcome data, identified
mental health needs of students, especially at a time when       needs, and demand.
students may have fewer interactions with peers, athletic
coaches, and advisors and that faculty may have an even          Ongoing Assessment and Evaluation
greater responsibility as gatekeepers.
                                                                 IHEs are encouraged to consistently assess the prevalence
The extreme academic, social, and economic pandemic-             and acuity of student mental health symptoms on their
related disruptions, the transition to virtual environments,     campuses. It is important to collect data to support
and constant uncertainty continue to take a toll on              strategic planning, resource management, and service
students’ well-being. For many, the pandemic can be              delivery models, including student satisfaction with
classified as a disaster with uncertainty being the main         telemental health services, as well as outcome data related
component; those with pre-existing mental health                 to efficacy of care. Campuses are encouraged to identify
conditions, low frustration tolerance, and/or limited            how best to collect data without further burdening a
coping strategies have been heavily impacted. The                virtual-weary population with additional electronic
American Psychological Association indicates that the            surveys.
negative mental health effects of the pandemic will be
serious and long-lasting.                                        Faculty and Staff Mental Health
ACHA and Healthy Minds survey data collected early in            The ACHA and Healthy Minds data indicate that there is a
the pandemic showed an increase in student incidence of          direct correlation between feeling valued and supported
depression and feelings of stress and anxiety. Student           and a sense of wellness. A strong predictor of wellness is
perceptions of loneliness and isolation have been cited as       believing that your voice matters and feeling like you are a
contributing factors. Some students report that mental           part of the decision making. For faculty and staff these
health services have been more difficult to access since         tenets are equally important. Campus leadership must
the pandemic. Early data suggesting increased incidences         continue to recognize and validate efforts on a consistent
of stress and mental health symptoms are juxtaposed with         basis and ensure that health, counseling, and health
data indicating improvements in student resiliency by            promotion staff as well as faculty and other staff continue
2.5% and decreased prevalence of risky drinking patterns.        to receive support, care, and resources on stress reduction,
                                                                 anxiety and depression management, and self-care.
Access to Care and Diversity of Services
The pandemic has accelerated the need for campuses to do         Mental Health Considerations
“business differently”. Now more than ever the need to            • Ensure mental health providers continue to comply
provide a menu of mental health and wellness services is            with current environmental, physical distancing, PPE,
vitally important. Counseling centers are creating options          and public health infection control measures.
other than the traditional in-person or virtual 50-minute
                                                                  • Institute appropriate safeguards for in-person
psychotherapy session. Students often want “just in time”
                                                                    sessions, including symptom screening, physical
services that are timely, convenient, and accessible. To
                                                                    distancing, and face masks for both client and
meet the need, counseling centers are offering “on
                                                                    provider.
demand” same day appointments, virtual walk -in clinics,
mental health chat groups, and encouraging the use of             • Develop and/or revise policies related to telemental
self-directed skill building modules and apps.                      health that are in line with accrediting bodies and best
                                                                    practice standards of care, including policies on
                                                                    education, training and credentialing of staff, and
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 6

     processes for monitoring competence with telehealth      comprehensive framework for supporting student
     protocols and practices according to local, state, and   compliance across multiple campus operational units and
     national requirements.                                   utilizing best public health and prevention practices.
                                                              Adapting policy and institutional operations to support
 • Develop and/or revise policies that guide clinical
                                                              health are core concepts of health promotion. The intent is
   practices and service provision, including policies on
                                                              to make healthy behaviors the easy choice through
   changes to the scope of services, patient
                                                              identification and removal of barriers to healthy action. In
   confidentiality and privacy, informed consent, crisis
                                                              this area, institutions have adopted a variety of health
   management, risk management, clinical
                                                              promoting actions during the pandemic:
   documentation, and system security.
                                                               • Changes to grading and attendance policies to allow
 • Outline steps required to offer services across state
                                                                 students greater flexibility.
   lines and communicate policies clearly to students.
                                                               • Changes to academic terms to reduce needed travel.
 • Encourage partnerships with faculty and other
   support departments such as financial aid and the           • Enhanced food security and aid for students in
   registrar’s office to promote connections and                 quarantine and isolation.
   opportunities to reinforce training on how to
                                                               • Enhanced access to technology for distance
   appropriately identify, intervene, and refer students in
                                                                 education.
   distress.
                                                               • Increased temporary aid for students in financial
 • Add mental health questions to existing surveys,
                                                                 distress.
   check-in processes, and functions to continuously
   take the wellness pulse of the campus population.           • Detailed infection control plans across the institution
                                                                 to provide structured, in-person opportunities to
 • For training facilities, ensure policies address how
                                                                 support well-being.
   trainees’ telemental health sessions will be
   supervised and whether sessions will be recorded for
                                                              Student Engagement and Community
   supervision.
                                                              Mobilization
 • Address the issues of compassion fatigue with the
                                                              Student engagement with institutional response to
   health and counseling staff and promote venues for
                                                              COVID-19 varies by campus, depending upon
   sharing and ongoing support. Identify wellness
                                                              institutional values and structures and operational factors
   resources, including the employee assistance
                                                              such as whether classes are remote or in person. Many
   program.
                                                              institutions that have transitioned to a primarily online
                                                              education model have seen a notable decrease in student
Health Promotion                                              engagement. Some institutions report lower student
Health promotion is a process—a network of coordinated        engagement across the board. Others report low student
actions—that supports individuals’ autonomy in creating       engagement generally, but consistent and sometimes
health and well-being. Health promoting actions include       increasing student involvement in health promoting
implementing health-supporting public policy, developing      activities, specifically those supporting mental and
healthy working and living environments, coordinating         emotional health.
collaborative community action, providing health              Students want opportunities to talk about and process how
education, and working with health care systems to think      COVID-19 has affected their college experiences and their
beyond treatment to promoting health as an everyday           lives. They want support in understanding the constantly
resource.                                                     evolving information about the virus and mitigation
Health promotion professionals are experienced in             efforts and applying these facts to everyday life. They
applying processes to multiple and varying focus areas.       want to know what they can do safely, as they are now
Health promotion processes can be applied to any health       well-versed in what they should not do. Students also are
outcome of interest, and every institution selects focus      clear that the pandemic has only exacerbated the already
areas for health promotion activities based on its unique     widespread concerns about mental and emotional health.
contextual characteristics.                                   A foundational tenet of health promotion is creating health
Senior health promotion professionals often have expertise    with the people and community served. Because of this,
in coordinating multi-layered, broad community action.        health promotion professionals are experienced in using a
They are uniquely skilled at developing and coordinating a
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 7

range of tools for community engagement and                     abilities to follow some public health guidance, such as
mobilization. As the pandemic evolved, health promotion         physical distancing.
professionals significantly expanded their use of
                                                                Harm reduction in application requires a belief that
technologies such as texting, social media, online meeting
                                                                students can make positive choices. It includes the
software, and apps. None of these tools are
                                                                provision of non-judgmental information, with a variety of
straightforward substitutes for in-person activities, and all
                                                                options for taking action. A principle of harm reduction is
require skill development for optimal implementation.
                                                                meeting people “where they are” and supporting
However, many of these tools are working well and may
                                                                autonomy in creating action plans. The overall goal is to
continue to be utilized post-pandemic, advancing
                                                                recognize that some students can’t comply with all
opportunities for community engagement.
                                                                physical distancing or mask guidelines while supporting
Pandemic response is complex, multi-faceted work and an         them in moving forward with implementing the guidelines
excellent learning opportunity for students in a wide range     that they can and are willing to do.
of disciplines. Inviting students to participate in
                                                                The harm reduction approach is easier to practice in one-
institutional planning and response allows them to see that
                                                                to-one conversations than in mass communication.
this type of work is not simple or one dimensional. They
                                                                Finding the balance between stating clear policy and
can observe and explore complex interactions of policy,
                                                                encouraging harm reducing behavior can be delicate.
organizations, and people. Additionally, students provide
                                                                People who have not previously practiced harm reduction
invaluable perspective on how to frame institutional
                                                                may have a steep learning curve to determine how to
decisions to best meet students’ needs. Institutions that
                                                                implement this approach. Health promotion practitioners
fully engage students in the pandemic response planning
                                                                have been key collaborators in making this work.
and implementation appear to have better results in
reducing negative impacts.                                      Health communication campaigns, often the result of
                                                                collaboration between health promotion and
Health Education and Behavioral                                 communication professionals, remain a critical tool during
Interventions                                                   the pandemic. Institutions have used every communication
                                                                channel (e.g., social media, email, text messaging, etc.) at
Many health education teams have pivoted to virtual             their disposal to ensure all students know physical
programs, sparking broad conversation about translating         distancing and mask guidelines, understand the facts of
evidence-based interventions designed for in-person             coronavirus transmission, and to motivate students to
implementation to the online environment. Health                follow guidelines. Specific tactics range from
educators have quickly gained knowledge in effective use        straightforward factual repetition of guidelines to social
of online meeting software to maintain privacy, allow for       norms and social marketing campaigns.
actively engaged participation, and support accessibility.
While sometimes difficult, the shift is also rapidly            Simple campaigns focused on factual repetition of public
expanding knowledge in ways that may forever change the         health guidelines are the most straightforward to
delivery of health education programs in higher education.      implement, especially with the plethora of resources
                                                                available from the CDC and other public health agencies.
In addition to transitioning standard programs, health          Effective social norms and social marketing campaigns
educators have developed programs specific to COVID-            are designed to enhance both motivation and factual
19. These programs are designed to influence individual         knowledge and require more depth of theoretical
behavior and enhance motivation to comply by increasing         knowledge, more detailed student information, and more
knowledge about physical distancing, mask wearing, and          resources for implementation to shape campaign
hand hygiene. It is important to note that none of these        messaging. Collaboration with the institution’s COVID-
tools are effective as singular interventions but rather        19 planning and response committee, marketing and
should be used in combination with complementary health         communications leadership, and the local community are
promoting activities.                                           critical for tailored, cohesive, branded, unified messaging.
Harm reduction, an approach that focuses on providing           Behavior pledges appeared as a widely used tool with
non-judgmental, non-coercive resources to reduce                varying levels of success. Some institutions used behavior
transmission of COVID-19 while acknowledging that the           pledges as an actual behavioral contract with clearly
disease can cause significant harm, appeared early in the       defined negative consequences if not followed. However,
pandemic response conversation. This approach allows            many institutions attempted to use the pledge as a social
opportunity for social justice, recognizing that many           contract, with efficacy coming from the aspects of social
factors—including social inequities—affect peoples’             accountability.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 8

For the social contract approach of pledges to work, it is    On-Campus Testing Procedures
recommended that:
                                                              To enhance the health, safety, and well-being of the
 • Whenever possible, student representatives                 campus and broader community, frequent testing is
   participate in the creation of their campus’ behavior      important and enables the institution to find asymptomatic
   pledge.                                                    or presymptomatic students and employees who may be
 • Students can personalize their own pledge, consistent      unknowingly spreading SARS-CoV-2.
   with their values and views of self.                       Until recently, CDC maintained its guidance to prioritize
 • Elements of the pledge be specific (e.g., I will wear a    testing to symptomatic individuals and close contacts and
   face covering when I ….) rather than general (e.g., I      briefly removed recommendations to test close contacts
   will social distance.).                                    altogether. Cumulative research and data led to CDC’s
                                                              revised tiered testing plan for IHEs.
 • Reasons why pledging to the behavior be included,
   possibly even combined with a dedication to                Hierarchy for selection of persons for IHE-based testing
   someone important to the individual (e.g., I’m doing       depending on community resources can be as follows:
   this for ______ because _____.).                              1. Persons with symptoms of COVID-19
 • Pledges be in writing. If a written pledge is not             2. Persons who have had close contact with someone
   possible, e-signing or initialing is more effective than         with COVID-19
   a click or social media share.
                                                                 3. All students, faculty, and staff with possible
 • Pledges be made publicly, to combine private as well             exposure in the context of outbreak settings
   as group accountability.
                                                                 4. Random sample of asymptomatic students, faculty,
 • Reminders of the commitment be systematically                    and staff to more rapidly detect increasing SARS-
   shared for reflection on match to behavior.                      CoV-2 incidence, with consideration for
 • Students receive positive reinforcement when pledge              incentivizing voluntary testing
   behaviors are demonstrated.                                   5. All students, faculty, staff and members of their
                                                                    place of residence as part of a community-based
Testing and Surveillance                                            testing strategy by health departments outside of
                                                                    outbreak settings
Testing must be integrated with swift identification and
containment of positive patients and contacts, physical       Diagnostic Testing
distancing, face coverings, and hand hygiene practices to
control the spread of COVID-19 on campus and within the       Diagnostic testing is performed when there is a reason to
community. COVID-19 diagnostic (PCR) testing for the          suspect that an individual may be infected with SARS-
virus allows for early identification, intervention, and      CoV-2. It is used to diagnose active infection in
effective contact tracing of COVID-19 cases. Testing          symptomatic individuals or those with recent exposure
results may also help the institution better understand and   and is sometimes used to determine resolution of the
mitigate the spread of the virus.                             infection. Daily health monitoring is an important adjunct
                                                              to diagnostic testing. Health monitoring allows students
A clearly defined comprehensive campus testing plan           and employees the opportunity to observe symptoms
based upon available resources, current scientific            quickly so that diagnostic testing can be performed as
evidence, and the needs of the campus community is vital.     early as possible. Examples of diagnostic testing are
Diagnostic screening and surveillance testing strategies      testing symptomatic individuals presenting to the health
are both important in reducing the spread of COVID-19         center and those who indicate that they were exposed to an
on college campuses. Evidence continues to mount in           individual with a confirmed or suspected case of COVID-
favor of frequent testing of campus constituents on a         19. Those with COVID-19 symptoms or deemed a close
recurring schedule. Campuses with limited resources           contact should immediately isolate/quarantine while
should consult with their local public health authorities     awaiting test results.
and/or local hospitals, labs, health care organizations, or
other IHEs for assistance.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 9

Screening or Asymptomatic Testing                               strategies such as physical distancing, wearing face
                                                                coverings, and avoiding large crowds.
Testing an individual when there is no reason to suspect
infection is known as screening. Screening is intended to       True random selection of the appropriate percentage of the
identify infected individuals prior to the development of       campus population can help the campus determine what
symptoms. Identifying asymptomatic positive cases of            percentage of the population may be infected with the
COVID-19 will allow campus officials to implement               virus. This is essential to planning, implementing, and
containment measures such as isolation/ quarantine to           evaluating public health practice on the campus.
prevent wider transmission. Screening for COVID-19 may          Typically, local, state, and federal authorities do not
be beneficial for individuals where physical distancing is      regulate surveillance testing; however, a sample of the
more difficult, such as first responders, emergency             campus population to test randomly and at regular
medical services staff, health care workers, those living in    intervals should be determined by the university using
congregate housing, and workers in other essential campus       local infection rates and trends and other epidemiologic
departments/services, such as food services.                    data. An example of surveillance testing is to select a
                                                                percentage of a random sample of the campus population
Pre-arrival testing is one example of screening. Some
                                                                on an ongoing basis, such as every 30 days.
institutions required pre-arrival documentation of a
negative test result before arrival to campus. The primary
                                                                Wastewater Surveillance
purpose of this testing is to identify individuals who test
positive, immediately isolate them, initiate contact tracing,   The emergence of COVID-19 has resulted in an increased
and prevent them from coming to campus while                    interest in wastewater surveillance. CDC considers
infectious.                                                     wastewater surveillance to be a promising public health
                                                                strategy as an early warning system for COVID-19
Entry testing or on-arrival testing is another example of
                                                                infection and initiated the National Wastewater
screening. This involves testing all students and
                                                                Surveillance System (NWSS) which coordinates the
employees returning to campus regardless of exposure,
                                                                assimilation of data from communities to health
signs, or symptoms. The results are then used to determine
                                                                departments and CDC. Approximately 30 U.S. IHEs have
what protective measures, such as quarantine or isolation,
                                                                implemented wastewater surveillance since students
are needed on an individual basis.
                                                                moved back to campus.
Screening may also involve frequent recurring testing of
                                                                COVID-19 virus is shed in the stool by approximately 50
individuals. More testing options, which are less invasive
                                                                percent of infected persons. It is considered an early
and conducive to point of care use, are becoming
                                                                community surveillance indicator since positive stool
available. The advantage of less expensive antigen tests
                                                                samples may precede case data by four to six days. Stool
has been somewhat offset by their lesser sensitivity.
                                                                can be positive in persons who are asymptomatic,
However, increasing evidence points to testing frequency
                                                                presymptomatic, or symptomatic. Persons who become
and rapid turnaround times as more important than the test
                                                                infected may shed the virus for weeks.
sensitivity for ongoing screening. The availability of
testing, as well as the funding and staff necessary to          Although wastewater surveillance is an emerging public
sustain frequent testing of students, faculty, and staff, are   health surveillance tool for COVID-19, there are some
key considerations driving institutions' decisions to           limitations. A positive test merely indicates the presence
implement a screening program.                                  of the virus and cannot be extrapolated to estimate the
                                                                prevalence of the virus within a community. Positive tests
Surveillance Testing                                            also do not necessarily indicate the presence of infectious
                                                                disease, since persons who are no longer infectious may
Surveillance is very important to gain information about
                                                                continue to shed virus. In addition, the absence of viral
the population rather than the individual person.
                                                                biomarkers in wastewater samples does not necessarily
Surveillance testing for COVID-19 includes ongoing
                                                                indicate absence of infection from a group, since not all
regularly scheduled testing and is helpful in determining
                                                                persons shed virus in their stool when infected.
the incidence and prevalence of COVID-19 on campus
                                                                Nonetheless, wastewater surveillance provides a real
and/or in the campus community. Surveillance testing can
                                                                benefit as an early indicator for the presence of the virus
provide an early warning system to identify hot spots
                                                                or trends within a tested community.
within the residence halls, off-campus community, or the
workplace and can help the campus understand if the             Various approaches can be used for establishing a
campus population is practicing effective mitigation            wastewater surveillance system. Universities may focus
                                                                on geographic areas on campus with elevated case rates,
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 10

or instead broadly assess samples from across campus.           them to interrupt disease transmission. This includes
Sewage lines need to be mapped and access to specific           asking cases to isolate and contacts to quarantine at home
building drainage is necessary. Samples are best collected      voluntarily.”
at least bi-weekly via site sampling or on a continuous
                                                                Contact tracing is a confidential process that has been
intermittent basis with an automated system. If testing is
                                                                used for years to curb the spread of infectious diseases and
too infrequent, or is of inconsistent timing, the benefit is
                                                                avoid outbreaks. To be effective, tracers must connect
diminished.
                                                                with known patients to identify and quickly alert their
Wastewater testing may be performed by various entities.        close contacts of possible SARS-CoV-2 exposure.
These include commercial labs or vendors, state public          Therefore, many student health services assumed contact
health labs, and university labs. These testing entities will   tracing of student cases to improve timeliness.
calibrate alert levels based upon their individual testing
                                                                In addition to notification of exposure to an infected
results. This data must be available to college health
                                                                individual, contact tracers communicate extensively to
centers in a timely fashion. They may use the data to
                                                                provide disease and transmission education; gather
advance testing or other public health mitigation strategies
                                                                information such as demographics, living arrangements,
in an affected area.
                                                                school and daily activities, and other pertinent data that
                                                                will assist in slowing the spread of COVID-19; and
Testing and Surveillance Considerations                         manage the individual’s case. Contact tracers will also ask
 • Though CDC does not specifically recommend entry             about signs/symptoms and underlying medical conditions
   testing all students, faculty, and staff, it does            and should have a system in place to direct those with
   acknowledge its value, stating that “In an IHE               symptoms to the appropriate health care or service
   setting, with frequent movement of faculty, staff and        provider. All contact tracers should complete a formal
   students between the IHE and the community, a                training to ensure consistent and quality information. The
   strategy of entry screening combined with regular            training may be provided by the local health department,
   serial testing might prevent or reduce SARS-CoV-2            CDC, or via a program such as the Johns Hopkins
   transmission.”                                               University COVID-19 Contact Tracing course.
 • Students, faculty, and staff with documented                 All communications should be consistent with the
   COVID-19 within the past 90 days should be                   institution's protocols, and the definition of a close contact
   exempted from the entry testing requirement.                 must be clearly understood. In October 2020, CDC refined
                                                                the definition of a close contact as an individual who was
 • The campus community should be tested on a
                                                                within 6 feet of an infected person for a cumulative total
   scheduled, recurring basis, with the ideal timing of
                                                                of 15 minutes or more over a 24-hour period starting from
   twice weekly for students with test result turnaround
                                                                2 days prior to illness onset (or, for asymptomatic patients,
   times of
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 11

 • Ability to gain trust of the contact to gather sensitive     disease outbreaks. With the emergence of COVID-19, the
   and accurate information.                                    relationship between SHS and state, tribal, territorial, and
                                                                local health departments has proven to be extraordinarily
 • The ability to conduct interviews without violating
                                                                important. Various models of relationships between SHS
   patient confidentiality.
                                                                and local public health entities have evolved. These may
 • Current knowledge of medical terms and principles            involve SHS reporting COVID-19 testing results, serving
   of exposure, incubation, infectious periods and              as a resource for testing and education, providing
   interactions, and symptoms of COVID-19 for both              community COVID-19 telephone support, or assisting
   presymptomatic and asymptomatic infection.                   with contact tracing. More closely shared models often
 • Exceptional communication skills and cultural                enhance the level of communication between the
   sensitivity.                                                 institution and the public health department with
                                                                purposeful location of public health contact tracers on
There are many different formulas or ratios that can be         campus and university volunteers or employees providing
used to determine the number of contact tracers an              contact tracing via the public health department.
institution must have in order to effectively manage the
case load. The estimate will be affected by the number of       Many public health jurisdictions have issued IHEs specific
cases over time, the percent positive rate, the                 guidance requiring certain public health activities—for
responsiveness of the persons being traced, the skill level     example, requiring the IHE to perform contact tracing on
of the individual contact tracers, and the technology that is   campus and provide community notifications, or to
used to streamline the information.                             identify and report outbreaks. The SHS should be aware of
                                                                these requirements and coordinate closely to ensure that
Many public health experts estimate a minimum need of           these obligations are fulfilled.
30 contact tracers per 100,000 population during a
pandemic. There are several contact tracing estimator           Traditionally, community public health entities have
calculators that can help campuses determine how many           provided hotlines or dedicated telephone numbers for
contract tracers are needed. One example is from the            community health questions. These COVID-19 hotlines
Fitzhugh Mullan Institute for Health Workforce Equity at        have been an important resource for many colleges and
George Washington University and is supported by the            universities. Some colleges and universities have
Health Resources and Services Administration (HRSA) of          implemented their own hotline and coordinated that
the U.S. Department of Health and Human Services                resource with their local public health entity.
(HHS). These estimator calculators will need to be              Bidirectional, timely, and frequent communication
adapted to the campus population.                               between the SHS and public health agencies is critical in
Considerations for contract tracing:                            the management of individual patients; early identification
                                                                of outbreaks; or development of new tools, treatments, or
 • Partner with local and state health agencies to              messages. Communication ideally includes scheduled
   augment contact tracing efforts and optimize                 frequent meetings with the public health epidemiologist,
   efficiency.                                                  public health officer, and SHS medical director or clinical
 • Provide formal training and resources for campus             leader.
   contact tracers.                                             Colleges and universities are a logical site for COVID-19
 • Recruit students in health-related fields such as            vaccine distribution. As vaccines become available, it will
   medical, nursing, and public health to augment               be important for SHS to plan with their local public health
   contact tracing staff.                                       agency how best to rapidly vaccinate their students,
                                                                faculty, and staff. Potentially, this collaboration could
 • Develop public service announcements and                     range from receiving vaccines from the public health
   campaigns outlining the importance of contact                program to distribution of the vaccine by the public health
   tracing and cooperation with contact tracers.                authority on campus. Each community is unique and
                                                                therefore communication with the public health authority
Coordination with Local Public Health                           will best determine an approach that is practical and
                                                                achievable.
Coordination of campus public health initiatives with local
public health resources remains a vital component of
college health. College health has had a longstanding
campus public health responsibility to coordinate activity
related to reportable diseases, vaccines, and infectious
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 12

Housing and Residence Life                                     • Campuses should continue to engage and meet the
                                                                 needs of vulnerable and marginalized campus
Careful preparation remains the key to an organized,             residential populations, including (but not exclusive
effective, safe, and medically informed reopening of             to) students at higher risk for complications from
campus housing in Spring 2021. Though deemed the                 COVID-19 and students with disabilities. Such
lowest risk approach, many colleges and universities were        students may benefit from enhanced priority for
unable to reduce on-campus housing to one student per            single rooms if this can be accomplished without
room or provide students with individual bathrooms. This         stereotyping, stigmatizing, or isolating the student.
was particularly challenging on smaller campuses with a          Additional recommendations can be found in the
high residential population.                                     ACHA Guidelines: Supporting Vulnerable Campus
The following, in conjunction with two person per room           Populations during the COVID-19 Pandemic (August
assignments, may be viable alternate and supplemental            2020).
approaches:                                                    • Campuses should ensure that custodial and residence
 • Placement of physical barriers between beds such as           life staff have access to sufficient and appropriate
   shower curtains or Plexiglas                                  personal protective equipment (PPE). Staff should
                                                                 review PPE donning and doffing procedures prior to
 •   Rearrangement of beds/placement head to foot for            the start of Spring 2021 semester.
     maximized distance
                                                               • High-touch surfaces should be cleaned and
 • Enhanced cleaning and sanitizing of high touch areas          disinfected regularly, and all residents strongly
 •   Universal masking requirements in common areas              encouraged to practice meticulous hand hygiene.

 • Early campus arrival with entry testing, modified           • The professional and student staff living in the
   quarantine, and rigorous recurring, scheduled SARS-           residence halls are particularly susceptible to mental,
   Co-V-2 testing programs (either all residential               emotional, and physical exhaustion and are at an
   students or random sampling)                                  increased risk of exposure to SARS-CoV-2 as they
                                                                 reside and work in a congregate setting. These staff
 • Pods, cohorts, or bubble assignments for students             need defined work schedules with time off as per
   who were then viewed as “family units”                        institutional policies, regular exercise and break
 • Decreased occupancy in community restrooms to                 opportunities, and psychological/counseling support
   accommodate physical distancing                               as needed.
 • Wastewater surveillance was utilized on some                • Resident advisers, college health services staff, and
   campuses as an early warning system to effectively            “student ambassadors” should begin educating
   identify SARS-CoV-2 and implement targeted testing            residential students about the importance, efficacy,
   in the residence halls before widespread transmission         and safety of the SARS CoV-2 vaccine. If possible,
   occurred.                                                     campuses should provide quick access to vaccination
                                                                 for residential students when their priority group is
Considerations for housing and residence life:                   reached, expediting high-risk individuals.
 • Campuses should consider their capability to isolate
   on-campus students from the larger community.             Isolation and Quarantine
   Campuses with a high proportion of students living
   on campus may be more effective in limiting spread        Most campuses provided spaces for isolation and
   than campuses with larger off-campus populations          quarantine (e.g., designated residence halls or floors,
   who may be mixing with on-campus students                 contracted hotels, apartments) and provided dining and
   socially.                                                 support services for ill or exposed individuals. Generally,
                                                             but not always, quarantine and isolation housing were
 • To maintain safe on-campus housing for students and       reserved for students who lived in on-campus housing.
   residential staff, campuses must continue to offer
   widespread testing, contract tracing, and                 Campuses experienced varied utilization of their isolation
   isolation/quarantine of ill and exposed individuals on    and quarantine spaces as cases of COVID-19 spread
   campus. This approach will continue to require            throughout campuses. Many developed systems to provide
   access to immediate testing for all students, faculty,    wraparound services to support students in isolation or
   and staff with symptoms.                                  quarantine. These services were resource intense and
                                                             required partnerships throughout campus to execute.
Considerations for Reopening Institutions of Higher Education for the Spring Semester 2021 / page 13

CDC made several significant changes to its isolation and       • Campuses should be discouraged from sending
quarantine guidance during the fall semester. In October          students home to isolate or quarantine in order to help
2020, CDC decreased the length of isolation to 10 days            prevent further community spread.
after symptom onset with resolution of fever for at least 24
                                                                • If adequate housing inventory exists, isolation and
hours (without the use of fever-reducing medication) and
                                                                  quarantine rooms should be physically separated
with improvement of other symptoms. For asymptomatic
                                                                  from other residential student rooms. If possible, a
individuals, isolation could be discontinued 10 days after
                                                                  specific residence hall or specific floors of a
their initial positive RT-PCR test for SARS-CoV-2. Those
                                                                  residence hall should be designated for quarantine or
individuals with severe illness may need isolation
                                                                  isolation.
extended to 20 days. Individuals previously diagnosed
with symptomatic COVID-19, who recover and remain               • The rooms should have private bathroom facilities
asymptomatic, do not need retesting within three months           and be supplied with a thermometer, sanitizing wipes,
after the date of original symptom onset. Those who               tissues, soap, hand sanitizer, and toiletries.
develop new symptoms consistent with COVID-19 within            • Rooms should be identified and labeled with
three months after symptom onset of the original COVID-           appropriate signage and access restricted to essential
19 infection may warrant retesting if no other diagnosis is       personnel providing services to these students.
plausible.
                                                                • The number of quarantine and isolation rooms
Though 14 days of quarantine remains CDC’s                        needed will be dependent on factors such as campus
recommendation if deemed a close contact to a person              size as well as the level of community spread of
with confirmed SARS-CoV-2 infection, CDC revised                  COVID-19. Preparation and planning must be made
quarantine guidance in December 2020, providing options           for the possibility of increased case numbers.
for reduced time in quarantine. Potential options to release
an individual from quarantine if permitted by local public      • Students should have a “COVID Plan” that include a
health authorities are:                                           list of items (medications, clothing, academic
                                                                  supplies, etc.) to bring with them to a quarantine or
 • After Day 10 without testing                                   isolation room.
 • After Day 7 after receiving a negative test result (test     • Student health services and/or residential life staff, or
   must be performed on Day 5 or later)                           their designees, should remotely monitor students
If quarantine is reduced to less than 14 days using either        daily (temperature checks and symptom screening).
option, the individual must:                                      Plans should be developed for further clinical
                                                                  evaluation if symptoms progress or worsen or the
 • Continue to monitor for symptoms through Day 14
                                                                  patient requests.
   after exposure.
                                                                • Dining services should arrange food delivery in
 • Monitor health and immediately self-isolate and
                                                                  collaboration with housing/residence life staff for
   contact the SHS, private health care provider, or local
                                                                  students on the campus meal plan. Student affairs or
   public health authority if new symptoms develop.
                                                                  campus life, in collaboration with housing/residence
 • Wear a mask, maintain 6 feet physical distance from            life staff, could arrange for the purchase of a campus
   others, practice hand hygiene, and avoid crowds.               meal plan or coordinate meal delivery for those
                                                                  students who have not purchased the campus meal
Considerations for isolation and quarantine:
                                                                  plan. Consider food vouchers or gift cards for
 • IHEs should discuss any changes in                             contact-free delivery.
   isolation/quarantine policies with their state, tribal,
                                                                • Counseling services and/or the office of spiritual and
   territorial, or local public health authority.
                                                                  religious life should be available remotely to students
 • Policy revisions should be coordinated and widely              in isolation or quarantine. Mental health care should
   communicated so all members of the campus                      be prioritized in recognition of the lack of physical
   community have a clear understanding of the                    and social contact during this time. Support teams
   requirements.                                                  could provide virtual wellness and entertaining
 • Protocols and procedures should be developed and               activities to help decrease feelings of loneliness and
   made available to all individuals involved in the              isolation.
   management of isolation and quarantine spaces.
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