Control of SARS-CoV-2 Infection Rates at a Spanish University With In-Person Class Attendance

Abstract

The “Safe Campus Program,” implemented in 2020 through 2021 at the University of Navarra (Spain), aimed to guarantee a safe return to university campus and prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks, avoiding university-wide lockdown. It included COVID-19 education, campus adaptation, and polymerase chain reaction (PCR) testing. We describe the main characteristics of the program and analyze the SARS-CoV-2 cumulative incidence among 14 496 university members. The 14-day cumulative incidence in the university was 415.2 versus 447.7 in the region. The program, sustainable in the long term, achieved low SARS-CoV-2 in-campus rates. (Am J Public Health. 2022;112(4):570–573. https://doi.org/10.2105/AJPH.2021.306682

During the COVID-19 pandemic, most Spanish universities adopted only online teaching. At university campuses, it was necessary to restore the quality standards of academic education, as well as to maintain a vibrant university life, an essential ingredient of higher education training.

INTERVENTION

The “Safe Campus Program” of the University of Navarra (Spain) aimed to prevent outbreaks of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) while keeping all in-person teaching and research activities. The program was based on three fundamental measures: education and training, campus adaptation, and polymerase chain reaction (PCR) testing and medical care (Figure B, available as a supplement to the online version of this article at http://www.ajph.org).

PLACE AND TIME

Between August 24, 2020 and May 30, 2021, a cohort study with a nine-month follow-up was carried out at the University of Navarra where in-person classes were held.

PERSON

At the beginning of the academic year, there were 14 496 members at the University of Navarra (57% women; median age = 21.9 years, interquartile range = 19.7–30.0) belonging to three campuses: Navarra (84.9%), Gipuzkoa (11.1%), and Madrid (4.1%). Students accounted for 83.1% of university members. Forty-five percent of university members lived with their families, 41.2% at a shared apartment, and 13.4% at a university residence (Table 1).

TABLE 1—

Baseline Characteristics of the University of Navarra Population During the 2020–2021 Academic Year: Spain

Characteristic	Students	Employees	P a
No.	12 050	2 446
Gender (female), no. (%)	6 887 (57.2)	1 342 (54.9)	.037
Age, y	23.87 (8.65)	44.56 (11.33)	< .001
Campus, no. (%)			< .001
Madrid	536 (4.4)	54 (2.2)
Navarra	10 311 (85.6)	1 990 (81.4)
Gipuzkoa	1 203 (10.0)	402 (16.4)
Accommodation, no. (%)			< .001
Family home	3 809 (33.8)	2 397 (98.0)
Shared apartment	5 619 (49.8)	39 (1.6)
Residence	1 846 (16.4)	10 (0.4)
Status, no. (%)
Undergraduate	9 794 (81.3)
Graduate	2 256 (18.7)
Research and academic staff		1 043 (42.6)
Administrative staff		1 403 (57.4)

Note. Continuous variables are expressed as mean and standard deviation and categorical variables as percentages.

^aChi-square test or the Student t test for qualitative or quantitative variables, respectively.

PURPOSE

Reopening educational institutions can be vital for the education and the physical and emotional health of many students.¹ Regarding university campuses, it was necessary to restore the quality standards of academic education and to maintain university life. The guarantee of a safe return to the university campus was essential for a return to normality and the best educational experience.

Spain was one of the countries most severely affected by COVID-19. After the first wave, the population SARS-CoV-2 seroprevalence was 5%; however, this percentage may represent an underestimate of the true burden of infection, given the subsequent high mortality rate during 2020.² We aimed to analyze the impact of a comprehensive preventive action plan against SARS-CoV-2 infection in a Spanish university that maintained in-person class attendance from August 2020 to May 2021, before youths were vaccinated in Spain.

IMPLEMENTATION

The program included three preventive activities (Figure A, available as a supplement to the online version of this article at http://www.ajph.org). The first one was COVID-19 prevention education and training for all university members. Before the academic year started, all university members received a citation for a PCR test and two guideline brochures (“Prepara2” and “Bienveni2”) providing information about preventive measures (social distancing, mandatory use of masks, hand washing) and the “COVID Area”: a 24-hour medical attention clinic that could be contacted by e-mail, telephone, or face-to-face. The COVID Area consisted of a team of 17 health care and community workers. Students and staff were mandated to contact the COVID Area if they had any COVID-19 symptoms or close contact with a positive case.

The second preventive activity was campus adaptation. Actions were taken in university spaces (e.g., indoor ventilation, tripled frequency of cleaning and disinfection, reorganization of desks and offices, reduction of classroom and office capacity, rescheduling of timetables, doubling of teaching hours) and personal measures (e.g., training of prevention measures, distancing, masks, hand washing, sanitizers).

Adherence to prevention measures was reinforced by “yellow vests”: personnel hired to ensure compliance. They recorded the reasons for each warning. Gate custodians helped to check the use of hand sanitizer upon entrance to the premises.

The third preventive activity was PCR testing and medical care. SARS-CoV-2 PCR testing was required of all university members to access the campus at the beginning of the academic year and after Christmas holidays. Additional random PCR testing was carried out after Easter break. PCR tests were also performed on individuals reporting COVID-19–related symptoms and on their close contacts in the university. During the academic year, weekly random PCR tests were carried out on a representative sample (mean: 268/week), stratified by employee or student status and center. All PCR tests were free.

The COVID Area was contacted for medical diagnosis and early case detection within the first 24 hours. More than 12 000 emails were received and answered. A secure database was designed and managed by the COVID Area to monitor in real time the impact of COVID-19 on the campus, allowing rapid action to be taken. The COVID Area also monitored all contact tracing and clinical care of people with positive PCR tests.

EVALUATION

A total of 34 848 SARS-CoV-2 PCR tests were performed (2.4 PCR tests/person); 71.76% of the PCR tests were retests: each person at the university received between two and eight PCR tests. The overall percentage of positive PCR tests during the study period was 3.5% (n =1232), and a positive PCR test was counted as a positive case of COVID. Women accounted for 44.4% of diagnosed positive cases; 85.9% (n = 1058) were students and 14.1% (n = 174) were employees. During the academic year, 8.5% of university members tested positive by PCR test. Of the positive PCR tests, 82.7% (n = 1019) occurred on the Navarra campus, 8.5% (n = 105) in Gipuzkoa, and 8.8% (n = 108) in Madrid. The different peaks were related to holiday periods. The first peak seemed to be related to Columbus Day (October 12), which is a public holiday and was a long weekend in week 41 (Figure 1).

FIGURE 1—

Number of Positive COVID-19 Cases and Percentage of Positive Polymerase Chain Reaction (PCR) Tests per Week at the University of Navarra During the 2020–2021 Academic Year: Spain

Overall, there were 4897 isolated individuals: 1232 positive cases and 3665 contacts, with a mean of 2.98 quarantined contacts for each positive case (Figure C, available as a supplement to the online version of this article at http://www.ajph.org). Of the positive PCR tests, 513 came from those previously classified as close contacts. The average reproductive number of SARS-CoV-2 during the study period was 1.36.

The 14-day cumulative incidence per 100 000 at the University of Navarra was 415.2 (95% confidence interval [CI] = 381.9, 448.6) and the 14-day cumulative incidence for the three regions was 447.7 (95% CI = 370.0, 525.3), with no significant differences between the university and the three regions combined (P = .113). The 14-day cumulative incidence on the Navarra campus was 405.1 (95% CI = 369.6, 440.6), whereas in the general population of Navarra it was 447.8 (95% CI = 406.9, 488.8), with no significant differences between the campus and the region where it was located (P = .121). The mean 14-day cumulative incidence on the university’s Gipuzkoa campus was 328.7 (95% CI = 301.6, 355.8), whereas in the Gipuzkoa general population it was 448.8 (95% CI = 419.6, 478.0), with significant differences (P < .001). The 14-day cumulative incidence on the smaller Madrid campus was 813.1 (95% CI = 735.9, 890.3), whereas in the general population of Madrid it was 441.8 (95% CI = 410.6, 473.1), with a significant difference (P < .001; Figure D, available as a supplement to the online version of this article at http://www.ajph.org).

The “yellow vests” carried out a total of 5313 admonishments (mean, 161 admonishments/week) (Figure E, available as a supplement to the online version of this article at http://www.ajph.org). When asked about the possible place of transmission, only 3% of the positive cases indicated that it was the campus.

ADVERSE EFFECTS

There were no adverse effects.

SUSTAINABILITY

The percentage of positive PCR tests in our study was 3.5%, below the 5% recommended by the World Health Organization,³ whereas in the general Spanish population it was 11.6% during the same period. In the general population of Navarra, this percentage was 8.8%.⁴ Other studies have shown a reduction in anxiety and improvement in safety behavior when applying similar measures.^5,6

This intervention shares many of its measures with the safe campus programs of other universities, such as Berkeley and Duke,^7,8 where mass testing, and compliance with individual prevention measures, led to reduced infection rates.⁹ All measures taken at the University of Navarra to ensure safety followed the international official guidelines and curbed the spread of SARS-CoV-2 infection.¹⁰

PUBLIC HEALTH SIGNIFICANCE

During the COVID-19 pandemic, continued in-person lectures and research activities at a university with a strong prevention program, including robust screening and contact tracing, did not generate a higher SARS-CoV-2 incidence than that observed in the community. The measures proposed in the “Safe Campus Program” were useful in reducing SARS-CoV-2 infection rates in our institution. These measures can be of great help to other institutions that have remained open during the pandemic and those that will do so in the future in similar contexts.