College Campuses and COVID-19 Mitigation: Clinical and Economic Value

Abstract

Background: Colleges in the United States are determining how to operate safely amid the coronavirus disease 2019 (COVID-19) pandemic.

Objective: To examine the clinical outcomes, cost, and cost-effectiveness of COVID-19 mitigation strategies on college campuses.

Design: The Clinical and Economic Analysis of COVID-19 interventions (CEACOV) model, a dynamic microsimulation model, was used to examine alternative mitigation strategies. The CEACOV model tracks infections accrued by students and faculty, accounting for community transmissions.

Data sources: Data from published literature were used to obtain parameters related to COVID-19 and contact-hours.

Target population: Undergraduate students and faculty at U.S. colleges.

Time horizon: One semester (105 days).

Perspective: Modified societal.

Intervention: COVID-19 mitigation strategies, including social distancing, masks, and routine laboratory screening.

Outcome measures: Infections among students and faculty per 5000 students and per 1000 faculty, isolation days, tests, costs, cost per infection prevented, and cost per quality-adjusted life-year (QALY).

Results of base-case analysis: Among students, mitigation strategies reduced COVID-19 cases from 3746 with no mitigation to 493 with extensive social distancing and masks, and further to 151 when laboratory testing was added among asymptomatic persons every 3 days. Among faculty, these values were 164, 28, and 25 cases, respectively. Costs ranged from about $0.4 million for minimal social distancing to about $0.9 million to $2.1 million for strategies involving laboratory testing ($10 per test), depending on testing frequency. Extensive social distancing with masks cost $170 per infection prevented ($49 200 per QALY) compared with masks alone. Adding routine laboratory testing increased cost per infection prevented to between $2010 and $17 210 (cost per QALY gained, $811 400 to $2 804 600).

Results of sensitivity analysis: Results were most sensitive to test costs.

Limitation: Data are from multiple sources.

Conclusion: Extensive social distancing with a mandatory mask-wearing policy can prevent most COVID-19 cases on college campuses and is very cost-effective. Routine laboratory testing would prevent 96% of infections and require low-cost tests to be economically attractive.

Primary funding source: National Institutes of Health.

Visual Abstract.. COVID-19 Mitigation on College Campuses

Many colleges and universities in the United States are attempting to continue undergraduate onsite learning and residential living during the COVID-19 pandemic. Modeling the outcomes, cost, and cost-effectiveness of mitigation strategies, such as social distancing, masking, and laboratory testing, can inform these efforts.

Figure.. Infections, costs, and economic efficiency, by COVID-19 mitigation strategy.

1timeLT = 1-time laboratory testing; CampusClosed = campus remains closed with only online education; COVID-19 = coronavirus disease 2019; DesigIsol = student isolation in a separate, college-sponsored location; ExtSocDist = extensive social distancing; ICU = intensive care unit; LT = laboratory testing; Masks = mask-wearing policies; MinSocDist = minimal social distancing; NoIntervention = campus operates as it did before COVID-19 without any mitigation interventions; NPI = nonpharmacologic intervention; ResIsol = residence isolation in student dorm room; RLT = routine LT; RLTqX = RLT every X days. A-C. The number and source of infections among students (A) and faculty (B) for each strategy, and total costs (C). On the left are the NoIntervention and CampusClosed strategies. The 4 broad NPI strategies (MinSocDist, ExtSocDist, Masks, and combined ExtSocDist and Masks) are further stratified by the use and frequency of LT, ranging from no LT, where those who report symptoms associated with COVID-19 are asked to isolate in their residence for 10 d; to 1 test for those who report symptoms to confirm placement in isolation; to RLT for all students and faculty at the start of the semester; to RLT among asymptomatic students and faculty at 3-, 7-, or 14-d intervals. Infections decrease as strategies increase in intensity, from MinSocDist to the ExtSocDist+Masks strategy. In each case, adding LT further decreases infections. Among students, most infections are from other students (A). Among faculty, depending on the strategy, most infections are from the community and other faculty (B). In strategies without RLT, hospital and ICU costs account for >50% of total costs (C). In strategies with RLT, testing accounts for >50% of total costs. Cost per test was $10. D. The efficiency frontier (cost per infection prevented) for COVID-19 mitigation strategies. The efficiency frontier represents the relationship between infections prevented (vertical axis) and total costs (horizontal axis). NoIntervention is shown in the open red circle on the lower left. Without RLT or testing at the semester start, regardless of isolation approach, there is clustering (ovals) of strategies involving MinSocDist (triangles), ExtSocDist (circles), Masks (diamonds), and ExtSocDist+Masks (squares). Unshaded ovals represent strategies where masks are not incorporated, and beige ovals represent clustering of strategies where masks are incorporated. More infections are prevented when masks are used. Symbols on the solid black line represent economically efficient strategies. The slope of the solid line represents the incremental cost per infection prevented for each strategy, compared with the next less costly efficient strategy. Testing at 14-, 7-, or 3-d intervals prevents additional infections, but at a substantially increased cost per infection prevented.