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Only a few weeks into the fall semester, colleges and universities across the country are urgently trying to control clusters of COVID-19 infections on their campuses. Thousands of cases have been reported nationwide, forcing universities to switch to virtual classes and either quarantine or, in some cases, send students back home whether or not they're sick.
The situation has become serious enough that Dr. Anthony Fauci, the nation's leading infectious disease expert, is urging colleges: If at all possible, do not send students home.
"It's the worst thing you could do," he said Wednesday on NBC's "TODAY" show. "When you send them home, particularly when you're dealing with a university where people come from multiple different locations, you could be seeding the different places with infection," said Fauci, director of the National Institute of Allergy and Infectious Diseases.
On Monday, Dr. Deborah Birx, coordinator of the White House coronavirus task force, cautioned governors on a call that college students could become a source of outbreaks beyond campuses.
"Sending these individuals back home in their asymptomatic state to spread the virus in their hometown or among their vulnerable households could really re-create what we experienced over the June time frame in the South," Birx said, according to a source on the call.
Nationally, two of the biggest outbreaks have occurred in Iowa, in the counties home to the largest universities in the state: Iowa State University and the University of Iowa.
Iowa State reported a spike in cases the second week of school, with a 28.8 percent positivity rate among students tested for COVID-19. And according to the University of Iowa's COVID-19 dashboard, nearly 1,000 students have tested positive within the past two weeks.
Both colleges are still holding some in-person classes, usually as long as they do not exceed 50 students.
Wednesday, a group of students and faculty members at the University of Iowa planned a "sickout" in a show of solidarity over concerns about "the rampant spread of COVID-19" on campus.
"As students and educators, we have seen firsthand that there is no safe way to hold classes in person during this pandemic," the group wrote online.
At James Madison University in Harrisonburg, Virginia, more than 400 cases of the coronavirus were reported less than a week after school started. University President Jonathan Alger announced plans to shift temporarily to online courses primarily and asked most students to leave campus by next Monday. The University of Notre Dame in Indiana has nearly 600 cases. Classes there switched to online only for two weeks, and the university is resuming in-person learning. Many students at North Carolina State University in Raleigh must move off campus this week.
Clusters were not unexpected. Put people in their late teens and early 20s into close quarters in dormitories and contagious illnesses are bound to spread, experts said.
"The college housing experience was not built for plagues," said Art Caplan, a professor of bioethics at NYU Langone Health. "They're going to wander. They're going to visit each other. They're going to go into town. They're going to sneak off and have a party. This is what they do."
What universities do next is critical, according to experts — their decisions could stop the spread of COVID-19, or keep it going.
"Some colleges have the capability of a dorm or a couple of floors of a dorm where they could keep people who are infected," Fauci said. "Keep them at the university in a place that's sequestered enough from the other students so that you don't get a cluster in the university, but don't have them go home, because they could be spreading it in their home state."
Many colleges have come up with plans to isolate sick students, with designated areas on campus for infected students who are not sick enough to be hospitalized.
The University of Wisconsin-Madison has set aside such housing for sick students to keep them in Madison. "The concern about sending all these college kids back home is that we potentially increase transmission in many communities," said Dr. Jeff Pothof, an emergency medicine physician who is the university's chief quality officer.
Indeed, sending all students off-campus — not just those confirmed to be infected — carries the risk of sending asymptomatic students home, where they could expose vulnerable family members.
"You potentially have a ton of people who don't even know they have the disease," said Dr. Rochelle Walensky, a professor of medicine at Harvard Medical School and an infectious disease physician at the Massachusetts General Hospital. "Five days later, they're going to come down with symptoms — or maybe even not — and now they're living with their parents."
It's been established that older adults and people with underlying health problems are at greater risk for more severe forms of the coronavirus, compared to children and younger adults.
Caplan suggests a different approach, at least when it comes to infected students.
"I think sending them home is better," he said, explaining that students' movements may be easier to control at home and that they may have better access to medical care depending on where they live.
What's more, keeping students on campus increases risks to instructors, cafeteria workers, and other support staff members, even people who deliver food to the dorms.
Caplan acknowledges that it is a complex situation, without a single answer for all universities.
North Carolina State freshman Kathryn Livoti is preparing to move home Saturday, even though she has been doing everything possible to reduce her risk for COVID-19.
"We just do homework all the time. It's pretty much all we do," said Livoti, 18. "I don't want to blame people who want to go out, because I want to, too. I just wish everybody had the mindset that if we want to stay on campus, we have to be careful."