Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021

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Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021
MAY 25, 2021

ACHA Guidelines
Considerations for Reopening Institutions of
Higher Education for the Fall Semester 2021

      n this second year of the pandemic, institutions of         in preventing transmission of the SARS-CoV-2 virus. The
      higher education (IHEs) and their faculty, staff, and       capability of COVID-19 vaccines to disrupt transmission
      students are optimistic that the fall 2021 academic         and reduce disease incidence is the single most valuable
      term will be far different than last fall, with a gradual   lesson learned in the past four months. Shifting resources
return toward normalcy. Even with the resumption of               to vaccinate the campus community will have wide-
research, academic, and co-curricular activities                  ranging positive implications for higher education, the
characteristic of a thriving campus, the unprecedented            economy, the health of the public, and the health of
disruption to campus communities and the widespread               individuals.
financial, academic, social, emotional, and physical
impacts resulting from the pandemic will require
institutional attention, resources, and planning on multiple
                                                                  COVID-19 Vaccination
fronts for the foreseeable future.                                On April 29, 2021, the American College Health
                                                                  Association (ACHA) published specific guidance on
Although COVID-19 vaccine is now widely available, not
                                                                  COVID-19 vaccination, stating that:
every eligible American will be vaccinated, making
achievement of community (herd) immunity elusive. The               where state law and available resources allow, ACHA
emergence of more transmissible variant strains of SARS-            recommends COVID-19 vaccination requirements for
CoV-2 may necessitate masking, hygiene, distancing,                 all on-campus college and university students for fall
cleaning, and disinfection to some extent this fall, and            semester 2021, in accordance with the IHE's normal
perhaps beyond. The testing, contact tracing, quarantine,           exemption practices, including exemptions for medical
isolation, and remote monitoring systems established over           contraindications. This recommendation applies to all
the past year should also be retained to some extent, with          students who live on campus and/or participate in on-
modifications made in accordance with case prevalence               campus classes, studies, research, or activities.
and as vaccination uptake increases in the campus
                                                                  On a campus where COVID-19 vaccination is required, all
                                                                  faculty, staff, and students are fully immunized, except for
In some respects, preparing for fall 2021 may be more             those with medical or religious exemptions. In such a
complicated than it was for the two previous academic             setting and where there is also low transmission in the off-
terms, as IHEs must maintain monitoring and surveillance          campus community, it will be possible to relax testing
processes, enforce masking and distancing, distinguish            requirements and other mitigation strategies, such as
between a vaccinated and unvaccinated cohort, provide a           masking and physical distancing (see CDC’s guidance for
rich and robust learning and living experience, and               people who are fully vaccinated). Testing will be
optimize the health and safety of a fully occupied campus.        necessary on an as-needed basis for diagnostic purposes.
It is a tall order in the face of two key unknowns—the
                                                                  If vaccination requirements are established only for
extent of variant strains of SARS CoV-2 and the level of
                                                                  students, relaxation of testing and mitigation strategies for
vaccination of the campus community.
                                                                  students is also possible. Existing CDC guidance states
Since the December 2020 release of the ACHA                       that fully vaccinated persons who are exposed to COVID-
Guidelines: Considerations for Reopening Institutions of          19 do not need to quarantine or, in most cases, be tested.
Higher Education for the Spring Semester 2021, three              With comprehensive vaccination, indoor classes, group
COVID-19 vaccines have received emergency use                     sizes, residence hall occupancy, eating establishment
authorization (EUA) by the US. Food and Drug                      operations, and sporting events may default to pre-
Administration (FDA). In addition, several vaccines have          pandemic guidance. Such an environment will be a new
been authorized for emergency use by the World Health             normal, but with continued need to seek local health
Organization (WHO). These vaccines have proven safe               department guidance and readiness to elevate COVID-19
and highly effective in preventing COVID-19; according            precautions depending on campus or community
to CDC, early data suggests the vaccines are also effective       transmission.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 2

If a COVID-19 vaccine requirement is not implemented, it            must be given to physical distancing, masking, airflow and
will be extremely important for IHEs to remain at                   filtering, and other infection prevention strategies.
heightened alert with their current oversight of population-
                                                                    PODs are usually classified as open or closed. Open PODs
based strategies to mitigate and contain the spread of
                                                                    are, as the name implies, open to all persons. This would
COVID-19. Physical distancing, masking, control of
                                                                    include campus members and non-campus members. Most
group sizes, appropriate ventilation, advanced testing
                                                                    state and federal vaccine sites have an open POD
strategies, and rapid contact tracing would likely need to
                                                                    designation. Closed PODs are limited to a specific
be continued. Communicating and reinforcing behavioral
                                                                    population, generally defined at a community level.
interventions will be particularly important as students
                                                                    College and university community definition would
arrive in the fall. New students may be unaware of the
                                                                    typically include all faculty, staff, and students. Spouses
campus culture, rules, and procedures for COVID-19
                                                                    and household members may be included. A closed POD
containment, and they may be less likely to have
                                                                    would not, however, include members outside of that
previously been infected and therefore lack immunity.
                                                                    community. Establishment of a Memorandum of
Fraternity and sorority rush; welcome events; the arrival
                                                                    Agreement with a local public health entity may be
of incoming students, including international students; bar
                                                                    beneficial in defining the POD and planned use of
patronage; congregate living, and various other group
                                                                    vaccines. 1
events may precipitate outbreaks when participants are not
fully vaccinated.                                                   As outlined by ACHA’s Mass Vaccination Clinic
                                                                    Guidance and Resources, COVID-19 mass vaccination
Some colleges and universities may choose a plan of
                                                                    events will require additional planning such as:
voluntary vaccinations but require a COVID-19 vaccine
declination. The declination process serves to inform the             • Attention to the event site layout and flow patterns
individual of the benefits and risks of vaccination vs. non-            for efficient and safe events, as well as a registration
vaccination and documents the individual’s choice.                      process for the event.
Additionally, the document provides an estimate of                    • Access to vaccine doses.
community risk. Any declination process should be
thoroughly reviewed by legal counsel and approved by the              • Security for vaccines and supplies.
governing body. Similar processes for vaccine declination             • Appropriate cold-chain management of vaccines.
have been used with health care employees for many years
(e.g., for hepatitis B vaccination) and on many campuses              • Consideration for providing appropriate PPE for
for students (e.g., meningococcal vaccination).                         staff, masking requirements for patient participants,
                                                                        and easy access to hand sanitizer/hand hygiene.
At this time, the need for COVID-19 vaccine boosters is
not known. Variants may demonstrate resistance to                     • Strengthening of community partnerships (e.g., with
vaccines and result in a need for boosters. Colleges and                local pharmacies, hospitals, health departments).
universities need to be well informed about booster                   • Addressing the needs of vulnerable and special needs
recommendations and be prepared to advise and                           populations.
potentially provide booster doses or referral to a local
resource.                                                             • Management of records, including connecting to state
                                                                        registries; sending reminders for additional doses as
Mass immunization involves distribution of vaccine to                   needed; and tracking of student immunization status.
large groups of persons in the most efficient manner.
These sites may be referred to as a “Point of Distribution”           • Encouraging use of CDC’s v-safe post vaccination
or “POD.” Efficient vaccine PODs may deliver each shot                  health check tool for COVID-19 vaccine symptom
in one to two minutes and have door-to-door experiences                 tracking and reporting.
of 25 or 30 minutes. PODs may be drive-through or walk-             In addition to the considerations included in ACHA’s
through. Drive-through PODs offer advantages such as                recommendation for COVID-19 vaccination requirements
reduced mixing of persons getting vaccinated but require            for all on-campus students for fall 2021, campuses should:
large spaces for car access, and accessing the site is
                                                                      • Develop strategies utilizing best practices to
difficult or impossible for those without a vehicle. Indoor
                                                                        maximize acceptance of vaccination, including
PODs are more accessible for persons by foot and offer
                                                                        understanding and addressing vaccine hesitancy,
climate control for workers and patients. Careful attention

  The Center for Infectious Disease Research and Policy (CIDRAP) provides templates, checklists, and other resources for planning a
closed dispensing site.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 3

     communicating messages targeted to the appropriate      campus COVID-19 mitigation plan. Testing is used for
     audience, providing incentives for vaccinations, or     diagnosis, screening, and surveillance. Viral testing with
     implementing vaccine requirements for subgroups         either a molecular test or antigen test is the mainstay of
     (such as those using campus housing, students in        testing. Molecular tests identify genetic material from the
     health professions, and athletes). ACHA’s Campus        virus and include the reverse transcription-polymerase
     COVID-19 Vaccine (CoVAC) Initiative will be             chain reaction (RT-PCR) tests and nucleic acid
     providing tools and resources to help IHEs address      amplification tests (NAATs). Molecular tests are highly
     vaccine hesitancy and promote vaccine uptake,           sensitive and have high specificity. However, most of
 • Utilize established resources and toolkits such as the    these tests need processing in a lab and have one to two
   Association of Immunization Manager’s COVID-19            days of turnaround time. Tests with a turnaround time of
   Vaccine Communication Resources or CDC’s                  15–45 minutes require specialized equipment and may be
   Vaccination Communication Toolkit to optimize and         difficult to implement at large scale. RT-PCR testing may
   tailor communications based on the audience .             identify many post-infectious cases and therefore have
                                                             diminished usefulness when used for screening.
 • Stay up to date with FDA guidance on vaccines.
   Attributes specific to the different COVID-19             Antigen tests identify specific proteins from the virus.
   vaccines, such as the requisite number of doses,          Antigen tests provide convenient, low-cost testing with
   storage requirements, and timing of doses, may            rapid results. However, they are less sensitive than
   influence vaccination strategies. Availability of         molecular tests and may require RT-PCR confirmation.
   vaccine and cold storage freezers may be primary          Their specificity is similar to that of molecular tests, and
   determinants of vaccine choice.                           their sensitivity correlates closely with the period of
                                                             COVID-19 infectiousness.
 • As vaccines become more widely available, college
   health centers should maintain an inventory of            Per CDC’s interim guidelines, antibody testing currently
   COVID-19 vaccines for routine administration.             has limited utility. Its primary uses are with the diagnosis
   Student health programs should anticipate providing       of multisystem inflammatory syndrome or other
   access to vaccines within their establishment or via      complications from COVID-19 and for epidemiologic
   other means, such as pop-up vaccination sites, and        studies. Currently, antibody tests are not to be used to
   should be prepared to vaccinate or direct to local        assess immunity status after COVID-19 vaccination, nor
   resources any students arriving to campus who are         are they to be used to determine the need for vaccination.
   not adequately immunized.                                 In some countries, antibody tests are being considered to
                                                             allow participation in international travel in lieu of a
 • IHEs should determine the adequacy of                     vaccine passport.
   immunization with vaccines not authorized by either
   FDA or by WHO in accordance with updated CDC              Home collection and at-home tests are becoming more
   recommendations regarding people vaccinated               common but are still relatively expensive for frequent or
   outside the United States.                                serial testing. If used for asymptomatic screening, these
                                                             antigen tests are most accurate if used on day 0 and again
 • Educate and train student-facing staff and faculty on     on day 3. Those tests that require samples collected at
   vaccination benefits, venues, and other resources.        home and sent away for testing may incur delays with
 • Provide guidance on getting a second dose of              results. Only those at-home testing products that have
   vaccine. If the initial dose of a two-dose vaccine was    FDA authorization should be recommended to patients.
   received prior to arrival on campus in fall 2021, IHEs    Large retailers are now providing rapid at home tests
   should share strategies with students for getting the     directly to consumers without a provider prescription.
   second dose by the same manufacturer either on            The data increasingly supports the frequency of testing,
   campus or in the local community.                         the speed of turnaround time and results notification, rapid
                                                             containment of positive individuals, contact tracing
COVID-19 Testing                                             efficiency and quarantine as more important than test
                                                             sensitivity. How frequently to test asymptomatic
COVID-19 testing remains a cornerstone for containment
                                                             individuals will vary depending on the level of immunity
and mitigation of the pandemic. Even with a fully
                                                             achieved on campus either through vaccination or
vaccinated campus, testing will still be required in some
                                                             recovery from natural disease, as well as the impact of
circumstances. It is crucial to have a clear understanding
                                                             susceptibility to variant strains and disease prevalence in
of the available tests; their uses, advantages, and
                                                             the community.
limitations; and their place in the context of the larger
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 4

Testing strategies on campuses have evolved significantly         the community itself, wastewater flow, viral shedding
since the onset of the COVID-19 pandemic. Most have               in feces, etc. remain constant, but trends may assist
established well-defined systems independently or in              with forecasting and mitigation. Sampling
collaboration with internal or external partners. Campus          wastewater is specialized and needs coordination
strategies now include an array of options such as                with campus environmental health services and
diagnostic testing, move-in screening, random screening,          facilities. Testing of the samples may be provided by
pop-up testing, wastewater surveillance, or genomic               campus-based labs, state labs, or vendors.
surveillance. CDC provides interim guidance for SARS-
                                                               • Genomic testing can determine the presence of
CoV-2 testing and screening at IHEs here.
                                                                 COVID-19 variants. Since November 2020, CDC has
 • Diagnostic testing is usually considered testing of           regularly been receiving samples for sequencing and
   persons with symptoms or potential exposure. This             evaluation from state and other public health
   may include testing persons with symptoms who are             agencies. They are also partnering with large
   being evaluated by a healthcare provider, testing as          commercial diagnostic labs and universities to scale
   part of contact tracing, testing unvaccinated persons         up sequencing. This work has led to the development
   exposed to COVID-19, or testing unvaccinated                  of the SARS-CoV-2 Sequencing for Public Health
   persons at an event attended by an individual with            Emergency Response, Epidemiology, and
   COVID-19. Whether fully vaccinated or                         Surveillance (SPHERES) consortium. Multiple
   unvaccinated, immunocompromised individuals,                  public health and scientific organizations, including
   including those taking immunosuppressants should              53 academic institutions, participate in SPHERES to
   be evaluated for testing if symptomatic, exposed to           share genomic data. In addition to sequencing, which
   COVID-19, or at an event attended by an individual            can be time consuming, labs could also re-test
   with COVID-19. For most persons, testing is not               positive samples using PCR probes that are specific
   recommended for determination of resolution of                to the more commonly circulating variants.
 • Screening tests may be used to test all students who
                                                               • Entry testing remains a valuable strategy to reduce
   move into campus-managed residential facilities at
                                                                 the spread of COVID-19. Some IHEs might opt to
   the beginning of the semester and may also include
                                                                 continue entry testing in order to identify
   testing all competitive athletes on a frequent basis
                                                                 breakthrough infections among vaccinated persons,
   (see NCAA's testing recommendation). When
                                                                 particularly when students are coming from
   community transmission of COVID-19 is moderate
                                                                 numerous points of origin. The IHE’s plan must
   (10 or more cases per 100,000 persons each week) or
                                                                 include the means to isolate and provide services and
   higher, CDC advises serial screening of all campus
                                                                 support for those who test positive.
   members on at least a weekly basis. This testing is
   contingent on resources. In response to an outbreak,        • Those who have been fully vaccinated and those who
   increased serial screening with contact tracing is            have been diagnosed with COVID-19 within the past
   likewise advised. Testing may take place with                 90 days may be exempted from entry testing and
   random selection of community members with                    surveillance testing. When designing campus testing
   molecular or antigen tests. To best function, results         programs, an individual or small select group should
   should be available as soon as possible and no longer         be assigned to monitor all the results in a systematic
   than 48 hours.                                                and regular basis. These results may give timely
                                                                 forewarning of an outbreak. An emerging challenge
 • Pop-up testing is a means for providing testing on an
                                                                 for institutions is assimilating multiple COVID-19
   as-needed basis in areas where individuals would
                                                                 data sources in a meaningful fashion.
   most benefit. Depending on the patient’s
   circumstance, this could be considered a diagnostic         • Pooled sampling can be used to reduce costs and save
   test or screening test.                                       time. It is a technique that is more beneficial when
                                                                 only a small number of positive results are expected.
 • Wastewater surveillance is a newer public health
                                                                 With pooled sampling, several patient samples are
   strategy which complements but does not replace
                                                                 tested together. If the test is positive, individual
   established surveillance methods. COVID-19 virus
                                                                 samples must be tested. This may result in a need for
   may be detected in wastewater preceding a rise in
                                                                 resampling those persons.
   case counts. Using wastewater surveillance results to
   estimate community prevalence is challenging unless
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 5

   • Diagnostic testing should remain available for               • Refer to the testing algorithm published by CDC to
     symptomatic people and those who have been                     assess when a confirmatory molecular test is
     exposed to an individual who is positive for SARS-             necessary after a positive antigen test:

    Source: U.S. Centers for Disease Control and Prevention, Interim Guidance for Antigen Testing for SARS-CoV-2

 • Generally, weekly asymptomatic testing should focus           Local health departments are responsible for leading
   on unvaccinated students, faculty, and staff, particularly    case investigations, contact tracing, and outbreak
   those living in a congregate setting.                         investigation. However, during the pandemic, many
                                                                 student health services assumed contact tracing
 • Health equity remains an important principle and
                                                                 responsibilities on campus to improve timeliness.
   should be considered in testing plans. All students,
                                                                 Contact tracing follows case investigation and is a
   faculty, and staff deserve equitable access to testing.
                                                                 critical mitigation strategy to prevent the further spread
   Testing criteria must be transparent, simple, and
                                                                 of COVID-19. According to CDC, contact tracing
   consistent. Positive results should be accompanied by
                                                                 “involves identifying cases and their contacts then
   referrals to accessible care or resources. Race and
                                                                 working with them to interrupt disease transmission.
   ethnicity must be reported with test results to local
                                                                 This includes asking cases to isolate and contacts to
   health departments. See CDC’s health equity
                                                                 quarantine at home voluntarily.”
   information and resources here.
                                                                 Contact tracing is a confidential process that has been
 • CDC does not currently recommend routine
                                                                 used for years to curb the spread of infectious diseases
   surveillance testing on fully vaccinated individuals or
                                                                 and avoid outbreaks. To be effective, tracers must
   those individuals within the 90-day window following
                                                                 connect with known patients to identify and quickly
   infection, unless COVID-like symptoms occur.
                                                                 alert their close contacts of possible SARS-CoV-2
Contact Tracing                                                  In addition to notification of exposure to an infected
Campuses should continue to offer testing, contact tracing,      individual, contact tracers provide disease and
and isolation/quarantine of ill and exposed individuals on       transmission education; gather information such as
campus. This approach will require access to immediate           demographics, living arrangements, school and daily
testing for all students, faculty, and staff with symptoms. As   activities, and other pertinent data that will assist in
case counts fall, the contact tracing workload should also       slowing the spread of COVID-19; and manage the
decrease. The capacity to expand and contract the contact        individual’s case. Contact tracers will also ask about
tracing workforce to meet demand will optimize efficiency        signs/symptoms and underlying medical conditions and
and conserve tight resources.                                    should have a system in place to direct those with
                                                                 symptoms to the appropriate health care or service
                                                                 provider. All contact tracers should complete a formal
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 6

training to ensure consistent and quality information.            • Provide formal training and resources for campus
The training may be provided by the local health                    contact tracers.
department, CDC, or via a program such as the Johns
                                                                  • Recruit students in health-related fields such as
Hopkins University COVID-19 Contact Tracing course.
                                                                    medical, nursing, and public health to augment
All communications should be consistent with the                    contact tracing staff.
institution's protocols, and the definition of a close contact
                                                                  • Develop public service announcements and
must be clearly understood. The definition of a close contact
                                                                    campaigns outlining the importance of contact
is an individual who was within 6 feet of an infected person
                                                                    tracing and cooperation with contact tracers.
for a cumulative total of 15 minutes or more over a 24-hour
period starting from two days prior to illness onset (or, for
asymptomatic patients, two days prior to test specimen           Masking and Physical Distancing
collection) until the time the infected person is isolated.
                                                                 Masking and physical distancing continue to be two of
Contact tracers must be able to provide recommendations          the most effective means of combating the spread of
for quarantine and understand local health department and        COVID-19. By now, IHEs have well-established
institutional policies for quarantine on and off campus.         policies, procedures, and physical reminders to comply
Many IHEs may not have the resources to offer quarantine         with mask mandates and distancing requirements.
and isolation accommodations for students who live off           CDC’s interim public health recommendations for fully
campus. However, as case numbers fall due to widespread          vaccinated people required IHEs to accelerate a review
vaccination, some IHEs may choose to offer quarantine and        of their current policies and procedures. Unless
isolation accommodations to students who live off campus,        vaccination is required or vaccination status is known,
particularly those with housing and food insecurity.             the IHE must rely on the individual to demonstrate
                                                                 personal responsibility and comply with campus
Resourcefulness may be the greatest skill needed for a
                                                                 masking and physical distancing guidelines.
contact tracer on a college campus since contacts may be
difficult to reach or reluctant to engage in conversations.      CDC’s updated recommendations for fully vaccinated
                                                                 individuals includes discontinuation of masking and
Additional contact tracer skills include:
                                                                 physical distancing requirements. IHEs must determine
 • Deep understanding of the structure of the IHE,               how to implement these new recommendations in
   including names of residence halls, terms that are            consultation with public health authorities; in
   frequently used by students and employees, and                accordance with the governing body or local, state,
   activities that are common among campus community             territorial, or tribal regulations; and with consideration
   members.                                                      of rates of immunization, infection, hospitalization, and
 • Knowledge of the resources on campus and in the               deaths in the campus and local community.
   community, such as testing, medical and mental health         Therefore, implementation of masking and distancing
   care, academic support, financial aid, and food or meal       guidelines could potentially include any of the
   delivery options for those in quarantine.                     following:
 • The ability to gain the trust of the contact to gather         • Fully vaccinated students, faculty, and staff may
   sensitive and accurate information.                              resume pre-pandemic instructional, research, and
 • The ability to conduct interviews without violating              co-curricular activities without physical distancing
   patient confidentiality.                                         or masking. Those who are unvaccinated (including
                                                                    those who are not fully vaccinated) must continue
 • Current knowledge of medical terms and principles of             to wear masks and maintain physical distance or
   exposure, incubation, vaccination status, infectious             attend class remotely. The IHE would need to
   periods and interactions, and symptoms of COVID-19               designate a section of the space or a percentage of
   for both pre-symptomatic and asymptomatic infection.             seats to accommodate unvaccinated individuals.
 • Exceptional communication skills and cultural                    Notably, without regulatory oversight or proof of
   sensitivity.                                                     vaccination, some may choose to disregard campus
Considerations for contact tracing:
                                                                  •    Require face masks and physical distancing for all
 • Partner with local, state, tribal, and territorial health          indoor public spaces, including classrooms, lecture
   agencies to augment contact tracing efforts and                    halls, gyms, etc., and all large outdoor gatherings
   optimize efficiency.                                               regardless of individuals’ vaccination status.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 7

 • Establish a threshold of vaccination of the campus               (without the use of fever reducing medications) and
   population before a blanket lifting of mask and physical         with improvement of other symptoms.
   distancing requirements.
                                                                 • An asymptomatic individual diagnosed with
 •   Develop a vaccine passport or other means to establish        COVID-19 should self-isolate for 10 days from the
     vaccine status to allow entry into classrooms or other        date of testing.
     public campus facilities.
                                                                 • Individuals who have tested positive for COVID-19
CDC continues to recommend six feet of physical distancing         with severe symptoms may need to extend self-
if not fully vaccinated. A notable exception is the decrease       isolation to 20 days.
in physical distancing standards from six feet to three feet
                                                               Quarantine (for those who are not fully vaccinated and
for children in K-12 classrooms, with the caveats of
                                                               who have been in close contact with someone diagnosed
concomitant universal mask wearing, meticulous hand
                                                               with COVID-19):
hygiene, and optimal ventilation. See the most up-to-date
CDC recommendations on masking and physical distancing         Although CDC still recommends 14 days of quarantine
for unvaccinated people; see also CDC recommendations for      for a close contact, they have provided other options.
fully vaccinated people.                                         • Unvaccinated individuals who have come in close
Considerations:                                                    contact (within 6 feet for more than 15 minutes)
                                                                   with someone diagnosed with COVID-19 could
 • IHEs should require unvaccinated individuals to
                                                                   end quarantine without a test for SARS-CoV-2 on
   continue to wear well-fitted masks and adhere to
                                                                   day 10.
   campus physical distancing guidelines.
 • All campus transit riders, regardless of vaccination
   status, should be required to wear masks and physically       • Quarantine can be ended on day 7 with a negative
   distance.                                                       SARS-CoV-2 test. The test must be performed no
                                                                   earlier than day 5. Individuals should continue to
 • Masks should be required in health care facilities or
                                                                   self-monitor for symptoms through day 14, wear a
   locations providing health or counseling services.
                                                                   mask, maintain physical distancing, and avoid
 • Local businesses and services may continue to require           crowds. If symptoms develop, quarantine should
   their patrons to wear masks. Local policies should be           resume and SHS or a private health care provider
   widely shared throughout the campus community.                  should be contacted.
 • Campuses should encourage individuals to carry masks,       Individuals who have been previously diagnosed with
   even if they are outdoors, in case they encounter a         symptomatic COVID-19 and have recovered and remain
   situation in which physical distancing is not feasible.     asymptomatic should not repeat testing for 90 days.
                                                               Those who develop new symptoms consistent with
Isolation and Quarantine                                       COVID-19 within three months may warrant retesting.
                                                               Individuals who have been fully vaccinated and are
Most campuses have provided spaces for isolation and
                                                               exposed to someone with COVID-19 do not need to
quarantine (e.g., designated residence halls or floors,
                                                               quarantine or undergo testing for SARS-CoV-2 but
contracted hotels, apartments) and have provided dining and
                                                               should continue to monitor for symptoms. Unvaccinated
support services for ill or exposed individuals. Generally,
                                                               individuals who are antibody-positive within 90 days of
but not always, quarantine and isolation housing are
                                                               exposure to someone with suspected or confirmed
reserved for students who live in on-campus housing.
                                                               COVID-19 do not have to quarantine if there is limited
However, some IHEs may choose to offer quarantine and
                                                               or no risk of exposure to persons at higher risk for
isolation accommodations to students who live off campus,
                                                               severe illness with COVID-19. See the full CDC
particularly those with housing and food insecurity.
                                                               guidance on isolation and quarantine.
Current CDC guidance for quarantine and isolation are as
                                                               Considerations for isolation and quarantine:
                                                                 • Policies should be coordinated and widely
Isolation (for those who have been diagnosed with COVID-
                                                                   communicated so all members of the campus
                                                                   community have a clear understanding of the
 • A symptomatic individual diagnosed with COVID-19                requirements.
   should self-isolate for 10 days from the start of
   symptoms with resolution of fever for at least 24 hours
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 8

• Protocols and procedures should be developed and              • Students in quarantine should have up to 60
  made available to all individuals involved in the               minutes of scheduled time outdoors daily for
  management of isolation and quarantine spaces.                  physical activity, if possible. While outside,
                                                                  students should wear their masks and maintain
• Campuses should be discouraged from sending students
                                                                  physical distance from others.
  home to isolate or quarantine in order to help prevent
  further community spread during transit.                      • To the degree possible, students should continue
                                                                  academic activities remotely or be provided with
• If adequate housing inventory exists, isolation and
                                                                  note takers.
  quarantine rooms should be physically separated from
  other residential student rooms. If possible, a specific      • A team of designated student affairs/campus life
  residence hall or specific floors of a residence hall           staff should be appropriately trained and on call to
  should be designated for quarantine or isolation.               assist students with their urgent personal needs
                                                                  (medication pickup, delivery of personal hygiene
• Ideally, rooms should have private bathroom facilities
                                                                  supplies, etc.).
  and be supplied with a thermometer, sanitizing wipes,
  tissues, soap, hand sanitizer, and toiletries.                • Policies and safeguards should be developed to
                                                                  avoid in-person socializing among students who are
• Rooms should be identified and labeled with
                                                                  being housed in isolation and quarantine spaces.
  appropriate signage and access restricted to essential
  personnel providing services to these students.               • Plans should be developed for transportation to and
                                                                  from isolation or quarantine rooms as well as to
• The number of quarantine and isolation rooms needed
                                                                  and from medical appointments as needed.
  will be dependent on factors such as campus size as
  well as the level of community spread of COVID-19.            • The IHE must provide appropriate PPE (as per
  Preparation and planning must be made for the                   CDC guidelines) and require custodial and
  possibility of increased case numbers.                          maintenance staff and live-in professionals to wear
                                                                  that PPE when cleaning or entering isolation and
• Students should develop a “COVID Plan” prior to
                                                                  quarantine spaces.
  arrival to campus that includes a list of items
  (medications, clothing, academic supplies, etc.) to bring
  with them to a quarantine or isolation room. Plans           Campus Access for Visitors and the
  should also identify individuals (i.e., family or friends)
  who will assist in securing and delivering needed items
  while in isolation.                                          In addition to students, faculty, and staff who access
• Student health services and/or residential life staff, or    campus spaces in a more controllable fashion, campuses
  their designees, should remotely monitor students daily      should also be prepared with policies and protocols
  (temperature checks and symptom screening). Plans            regarding other persons who might need or wish to gain
  should be developed for further clinical evaluation if       access to these spaces (e.g., official guests, informal
  symptoms progress or worsen or the patient requests.         visitors, and the general public). Such access might
                                                               include brief visits for meetings and tours; informal
• Dining services should arrange food delivery in              visits for the purpose of casual interaction with specific
  collaboration with housing/residence life staff for          students, faculty, or staff; participation in youth
  students on the campus meal plan. Student affairs or         programs; and attendance at conferences, symposia,
  campus life, in collaboration with housing/residence         sporting events, performances, convocation,
  life staff, could arrange for the purchase of a campus       commencement, or other special events. Moreover,
  meal plan or coordinate meal delivery for those              campuses might include spaces that were traditionally
  students who have not purchased the campus meal plan.        used by the general public (for example, restaurants,
  Consider food vouchers or gift cards for contact-free        food courts, museums, parks/gardens, etc.).
                                                               Visitors include family members, significant others,
• Counseling services and/or the office of spiritual and       alumni, sports fans, students from other colleges and
  religious life should be available remotely to students      universities, vendors, contractors, opposing athletic
  in isolation or quarantine. Mental health care should be     teams (players, coaches, support staff), patients and
  prioritized in recognition of the lack of physical and       families at academic medical centers, off-campus EMS
  social contact during this time. Support teams could         crews and law enforcement officers, public health
  provide virtual wellness and entertainment activities to     officials, financial donors, and tourists.
  help decrease feelings of loneliness and isolation.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 9

Campuses should assess multiple factors including the             • Decide how restrictions might be modified based
health of visitors and the overall health of the campus             upon variations in the level of community risk
community to determine the level of access available to the         (e.g., community infection rates, vaccination levels,
public. When disease prevalence is increasing on campus or          etc.).
in the surrounding community, campuses should
                                                                  • Consider whether there will be age restrictions for
explore modified, lower risk alternatives such as virtual
                                                                    some activities or spaces.
platforms, outdoor activities, and limited in-person
capacity. Specific rules will vary from campus to campus          • Review local and state public health guidelines to
based upon resources and local risks.                               ensure compliance with applicable regulations.
                                                                    Rules that are specific to the IHE may not apply
Questions and considerations when planning for the
                                                                    when the spaces are also used by the general
presence of visitors, guests, and the public:
 • Decide which campus spaces are open to visitors and
   which are limited to official students, faculty, and staff.   Student Health Services
 • Determine the behavioral expectations of visitors while
   on campus (e.g., masking, distancing) and how will this       The role of student health services (SHS) has continued
   be conveyed and enforced.                                     to expand during the COVID-19 pandemic, with SHS
                                                                 often adding testing, contact tracing, and case
 • Assess the origin of visitors and whether that influences     management to their responsibilities. As vaccines have
   the level of risk: are visitors from the local vicinity or    become available, many SHS are also providing on site
   more distant places? Are they arriving from higher risk       COVID-19 vaccinations. Campuses will continue to
   countries?                                                    look to student health services for medical and public
 • Determine whether any type of screening will be               health expertise, and SHS leadership should be poised to
   required upon entry (e.g., verbal symptom attestation).       deliver current, sound, evidence-informed
                                                                 recommendations. Maintaining essential services to
 • Whenever possible, rules for visitors should mirror
                                                                 students while providing pandemic-related care and
   those for students, faculty, and staff who use the same
                                                                 campus support continue to challenge the campus health
 • Determine the occupancy limits of each space in which
   visitors will be permitted and how the limits will be         Patient Care Considerations
                                                                 As campuses begin to reopen more fully to in-person
 • Decide whether viral testing will be required for certain     learning, there will likely be an increased demand for
   visitors (e.g., for visitors participating in higher risk     health care services. Student health services should plan
   activities such as large gatherings, events with food and     for and anticipate more requests for in-person visits. To
   drink, or other mask-free interactions).                      be fully prepared, SHS should:
 • Place masks and hand sanitizer at highly trafficked            • Develop protocols for in-person visits. Consider
   building entries.                                                designating providers for telemedicine and in-
 • Decide which segments of the campus population will              person visits on a daily basis. If possible, allocate a
   be permitted to have guests (e.g., undergraduates living         separate area of the clinic for acute illness.
   in residence halls).                                           • Continue the delivery of routine clinical preventive
 • Where feasible, maintain a registry of guests to                 services when possible to prevent health
   facilitate contact tracing.                                      consequences of delayed care.
 • Place increased signage at entrances to (and within)           • Continue to provide options for telemedicine or
   spaces used by the general public, as visitors will be           telephone consults when appropriate. Students with
   less knowledgeable about campus rules and protocols.             conditions placing them at higher risk for
 • For performances, consider the safety of performers as           complications from COVID-19 and who have not
   well as audiences. Distancing between audiences and              been vaccinated should be encouraged to seek care
   performers may need to be greater when performers are            via telemedicine when possible (some symptoms
   projecting their voices or blowing into instruments. Use         may require in-person clinical assessment).
   masks and instrument bell covers to reduce droplet             • Advise patients to call before coming to the SHS
   spread.                                                          for any type of visit.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 10

• If possible, utilize an online or telephone process for       • Work closely with the marketing and
  patient check-in.                                               communications department to provide updated
                                                                  messaging about COVID-19 protocols, policies,
• Limit student contact with SHS computers/keypads.
                                                                  and services as well as the importance of COVID-
  Have students complete and submit forms (health
                                                                  19 vaccinations. Use a variety of platforms
  history, immunizations, consents, etc.) via the patient
                                                                  including websites, social media, and signage.
  portal or utilize EHR templates.
                                                                  Involve as many campus entities as possible in
• Require all patients and clinic guests to wear well-            communicating these messages (housing, dining,
  fitted, multi-layer cloth face masks or provide patients        recreation services, etc.).
  with a medical procedure (surgical) mask.
                                                                • Work closely with residential life staff to identify
• Limit visitors, children, or accompanying guests who            and manage students who require isolation or
  are not receiving care or services from entering the            quarantine.
                                                                • Develop relationships and agreements with local
• Screen all patients and staff for COVID-19 symptoms             emergency departments (ED) to accept ill patients
  before entering the clinic when local conditions suggest        requiring a higher level of care.
  ongoing risk.
                                                                • Consider embedding a mental health clinician
• Develop a plan for students with respiratory symptoms           within the SHS to provide easier access to mental
  who need transportation to SHS, housing, or local               health services and improve collaboration and
  hospitals. Ensure after-hours care options are included.        coordination of care between health and counseling
• Update screening forms to incorporate COVID-19                  services.
  symptoms, including but not limited to: fever, cough,
  shortness of breath, chills, muscle pain, headache, sore     SHS Facility Considerations
  throat, congestion, nausea, vomiting, diarrhea, and loss      • Design facility layout to provide in-person clinical
  of sense of smell and taste (anosmia and dysgeusia).            services for needed preventative care and care for
• Include a question about COVID-19 vaccination status            illnesses/injuries other than COVID-19 in the safest
  on screening forms.                                             manner possible while minimizing transmission of
• Establish protocols for managing patients with acute
  respiratory symptoms, including masking the patient,          • If possible, segregate waiting areas for ill and well
  quickly rooming the patient, limiting and tracking the          patient visits.
  number of staff who enter the room, limiting the              • Perform COVID-19 testing in a separate location of
  movement of the patient throughout the SHS, and                 the clinic or outdoors when possible.
  cleaning of spaces where the patient was present.
                                                                • Configure all waiting and other clinic areas to
• Avoid use of nebulizers and peak flow measurements              promote physical distancing.
  which can generate additional aerosols. Follow best
                                                                • Ensure adequate amounts of alcohol-based (at least
  practices to reduce risk when nebulizers are used (e.g.,
                                                                  60%) hand sanitizer, surgical masks for patients
  distancing, PPE, separation of patients who require
                                                                  who do not bring their own mask, tissues, and
  nebulizer treatment behind closed doors, use disposable
                                                                  closed bins for disposal are available.
  tubing and other supplies).
                                                                • Provide plexiglass/clear barriers between reception
• Ensure a COVID-19 testing plan is in place for
                                                                  staff and waiting areas.
  students, faculty, and staff, either on- or off-site.
  Frequency and type of testing may vary depending on           • Develop protocols for environmental management,
  community and campus resources.                                 including frequency of and responsibility for clinic
                                                                  cleaning and decontamination.
• If possible, provide vaccinations at SHS and offer the
  vaccine to unvaccinated students at all routine visits. If    • Assess air exchange and filtration in care,
  this is not feasible, provide community resources and           treatment, and administrative spaces and determine
  locations for vaccine appointments.                             time required between uses in the event of a known
                                                                  or suspected COVID-19 patient. Facilities may
• If dental operations are within the scope of services,
                                                                  need to consider updating air handlers and
  review updated CDC Guidance for Dental Settings.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 11

    negative-pressure rooms/tents and conducting some            • Identify appropriate charges (if indicated) for visits,
    visits outside. Portable HEPA filters may be necessary,        telehealth services, testing, and supplies, including
    but they should be placed so that airflow is not directed      medications or vaccines. Identify correct billing
    from one person to another person.                             codes to facilitate prompt, accurate reimbursement
                                                                   if billed to insurance.
 • Ensure adequate IT network, wi-fi, hardware, and
   expertise to support telemedicine and telemental health
   visits.                                                      Mental Health
                                                                The COVID-19 pandemic has significantly increased
SHS Administrative/Staff Considerations
                                                                the mental health needs of our campus communities due
 • Utilize patient satisfaction surveys to obtain feedback      to the consistent stress related to fear and uncertainty;
   about telemedicine or phone visits as well as clinic         burnout; and a sense of powerlessness, sorrow, and loss
   services. Develop a system to review the quality of care     that has characterized life for so many. There is clear
   provided and incorporate into existing peer review           consensus that there will be a considerable
   processes.                                                   psychological and psychiatric aftermath to this
 • Ensure adequate PPE is available and that all staff are      pandemic, resulting in high demand for counseling and
   trained in its use. Monitor staff compliance with PPE        psychiatric services when students return in the fall.
   use. Enough PPE supplies should be stocked to meet           The pandemic’s mental wellness impact was widely
   both patient care and testing needs. Establish Periodic      experienced but affected some more than others. Those
   Automatic Replacement (PAR) levels for PPE                   who reported the poorest mental health were young
   restocking, if such guidelines are not already in place.     adults and individuals with financial adversity or those
 • Maintain situational awareness of COVID-19 incidence         unable to receive care for other medical conditions.
   and prevalence in the state and city and on campus.          According to CDC, one in four young adults age 18–24
                                                                seriously considered suicide in spring 2020. The 18–24-
 • Require frontline SHS staff to be vaccinated for             year age group appears to be especially vulnerable,
   COVID-19.                                                    possibly due to many of the drastic transitions they were
 • Consider a mandatory COVID-19 testing policy for all         required to make and the isolation they experienced at
   unvaccinated SHS staff.                                      what is typically a highly social stage of life. Factors
                                                                such as inadequate sleep, exercise, or face-to-face
 • Implement effective patient-centered policies to safely      socialization also increased the risk for poorer mental
   meet the health and counseling needs of students.            well-being. One of the most salient factors is not
 • Develop employee health program protocols for                knowing when the pandemic and its consequences will
   management of exposed and ill staff members. Develop         end.
   return to work protocols for staff who have become ill       Other risk factors associated with poor mental well-
   or were exposed to COVID-19.                                 being include:
 • Document all providers and support staff involved in          • Having a pre-existing mental health condition or
   the care of every patient so that exposures can be              substance use disorder.
   tracked.                                                      • Identifying as a sexual or gender minority,
 • Ensure staff are knowledgeable about COVID-19                   including transgender and nonbinary.
   symptoms, transmission, relevant protocols, and               • Being a first-year college student or high school
   updated CDC guidance.                                           senior.
 • Develop plans for alternative work assignments for            • Being a member of a marginalized population.
   unvaccinated staff at higher risk of severe COVID-19.
                                                                 • Lacking social support.
 • Continue to track costs and funding mechanisms for            • Having previously experienced trauma, having a
   testing, contact tracing, and case management.                  childhood history of traumatic experiences.
   Consider the financial impact of mass vaccination with
   COVID-19 vaccine.                                             • Experiencing poverty or lack of resources.

 • Develop plans for mass immunization with COVID-19             • Being a community college student and/or adult
   vaccine, including necessary personnel, supplies, and           learner.
   locations for vaccination administration and delivery.        • Having a chronic illness, including long-term
                                                                   effects of COVID-19.
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 12

According to the Center for Collegiate Mental Health                  anchored with the campus in their first year.
(CCMH), students who perceived that their “mental health”
                                                                  • Facilitating the diverse responses to the transition
was negatively impacted by COVID-19 and sought
                                                                    back toward pre-pandemic daily routines.
counseling treatment reported higher levels of mental-health
distress in the following areas:                                  • Attending to the basics of food, shelter, and
 •   Depression,
 •   Generalized anxiety,                                         • Addressing academic worry, a key factor of
                                                                    reported distress as well as the anxiety related to
 •   Academic distress, and
                                                                    the uncertainties surrounding the pandemic.
 •   General distress symptoms and overall wellness.
                                                                  • Embracing resiliency programming that includes
The data indicates that 85% of students seeking counseling          providing credit courses and implementing skill-
services report that COVID-19 has negatively impacted at            based practices within student affairs and academic
least one aspect of their life:                                     programs.
 •   Mental health (65%),
 •   Motivation or focus (61%),                                  Counseling and Psychological Services
 •   Loneliness or isolation (60%),                              Since the onset of the pandemic, counseling services
 •   Academics (59%), and                                        implemented new and expanded services and delivery
                                                                 methods including:
 •   Missed experiences and opportunities (54%).
                                                                  • Transitioning to digital and virtual platforms vs. in-
Mental Health Strategic Planning                                    person individual and group sessions.
Now more than ever, a comprehensive public health                 • Expanding crisis services.
approach is needed to address the looming mental health           • Providing on-demand virtual psychoeducation,
impact of the COVID-19 pandemic. Mental health must be              support, and therapy sessions.
viewed not just from an individual psychopathology level
but from a public health standpoint. College counseling           • Providing training and education that help students
centers do not have the capacity to provide treatment to so         at risk, including bystander intervention and
many students on an individual level, nor should they. This         gatekeeping suicide prevention programs.
is the time to engage and unite the campus in the goal of         • Enhancing partnerships with other departments to
providing a safety net for students, faculty, and staff. There      provide consultation and support.
is an acute need to bolster resilience and create an
environment of compassion and understanding. The campus           • Enhancing web presence with digital offerings and
should engage in strategic planning that is inclusive and           self-help options.
considers not only the impact of COVID-19 but also               Counseling services will likely retain or expand many of
proactively addresses the intersection of related academic,      these offerings this fall.
social, and institutional issues.
                                                                 Colleges and universities should anticipate the need for
College and university leadership should prepare to address      enhanced mental health services and develop plans to
the continuous and future challenges encountered by the          support the mental health needs of students returning to
campus community caused by the pandemic. As students re-         campus. This has been a year of distancing from social
integrate into campus, leadership’s focus should include:        and interpersonal interactions and friendships. Students
 • Improving access to mental health care, improving             may have greater levels of anxiety upon return to a
   students’ experience of mental health, integrating            social campus environment and greater opportunity and
   mental health issues and resources into class syllabi,        access to alcohol and other drugs.
   and creating space for listening.                             Considerations for counseling centers:
 • Supporting resilience through consistent engagement            • Make an institutional commitment to providing
   with peers, leadership, and decision makers.                     more resources to college counseling centers.
 • Promoting healthy coping strategies through social             • Provide clinician training and utilization of
   norming.                                                         evidence-based trauma-informed practices specific
 • Fostering social connections and opportunities,                  to assessment and treatment (see appendix A).
   especially for second-year students who may not have
Considerations for Reopening Institutions of Higher Education for the Fall Semester 2021 / page 13

• Provide clinician training about substance use                    parents, faculty, and staff. The Jed Foundation and
  disorders.                                                        the Suicide Prevention Resource Center (SPRC)
                                                                    provide valuable resource options.
• Continue diversification of services by providing a
  menu of service options for students to include virtual,      • Coordinate medical and counseling services.
  digital, and in-person options.                                 Collaboration between medical services and
                                                                  counseling and psychological services must be
• Continue providing crisis management services;
                                                                  seamless, with a focus on eliminating barriers and
  SAMHSA provides a comprehensive guide on best
                                                                  promoting access to care. Since students often
  practices in providing mental health crisis services.
                                                                  initially present to SHS, it should adopt a wellness
• Continue collaborations with campus partners.                   assessment in addition to a depression inventory to
• Focus on in-person and virtual same day appointments            proactively address the magnitude of physical,
  and “on demand” counseling options.                             emotional, and spiritual effects resulting from the
                                                                  pandemic. Screenings need to embrace a trauma-
• Provide options for drop-in counseling.                         informed approach with clear pathways for
• Create stepped care venues that provide the correct type        intervention and referral.
  and level of service based on the student’s presenting        • Provide easy access to behavioral health providers.
  needs and functioning.                                          The practice of embedding behavioral health
• Provide counseling services through remote service              providers in primary care has had enormous
  options, taking services to where the students are              success in both the private and public sector and
  (residence halls, academic buildings, etc.). Collaborate        allows for improved access to care, coordination,
  with campus partners to ensure secure, private spaces           and a welcome warm hand-off.
  for students to access remote care.                           • Provide opportunities for virtual telehealth sessions
• Focus on normalizing and increasing help-seeking                and consider safe in-person visits without masks,
  through consistent marketing, timely triage, and                with adequate distancing, ventilation, and
  improving ease of access.                                       immunization; this acknowledges the value of
                                                                  facial expressions in providing accurate
• Designate peer-based outreach and peer-based support            assessment, evaluation, and rapport building.
  groups provided virtually or in-person.
• Create service-learning opportunities on campus and in       Health Promotion
  the community to encourage students to get involved as
  a part of the solution.                                      Health promotion is a process—a network of
                                                               coordinated actions—that supports individuals’
• Promote a work/life balance and a healing                    autonomy in creating health and well-being. Health
  environment. Counseling staff are consistently               promoting actions include implementing health-
  addressing diverse and acute mental health needs of          supporting public policy, developing healthy working
  students while balancing their own personal stressors.       and living environments, coordinating collaborative
  Provision of therapy services through video can be           community action, providing health education, and
  more emotionally draining for mental health                  working with health care systems to think beyond
  professionals. There is a need for acknowledgment and        treatment to promoting health as an everyday resource.
  recognition for the important work that is done. The
  work climate must encourage and embrace self-care,           Health promotion processes can be applied to any health
  collaboration, and focus on staff retention.                 outcome of interest, and every institution selects focus
                                                               areas for health promotion activities based on its unique
• Enhance gatekeeper strategies. Students will need a          contextual characteristics.
  comprehensive approach to help maximize their
  strengths and engage in healthy habits such as finding       Senior health promotion professionals often have
  social/academic balance, eating a nutritious diet,           expertise in coordinating multi-layered, broad
  exercising, and developing healthy sleep patterns. It        community action. They are uniquely skilled at
  takes all campus stakeholders to encourage wellness,         developing and coordinating a comprehensive
  but also to identify those in distress. The need to cross-   framework that effectively engages students in
  train all front line personnel to recognize and respond      supporting healthy behaviors while utilizing best public
  to trauma and identify risk factors needs to be a            health and prevention practices. Adapting policy and
  priority. The training should include students as well as    institutional operations to support health are core
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