Mumps tore through the Harvard University campus in the spring of 2016. As a reportable disease that has been relatively manageable since a vaccine was approved in 1967, mumps serves as a warning of how viruses can spread rapidly — and in unexpected ways — with lessons for understanding SARS-CoV-2, the virus that causes Covid-19.
Dormitory residents, dining hall staff, athletes, and health services nursing staff all came down with mumps. A commencement event infected Harvard affiliates who went on to seed an outbreak in a neighboring community. Mumps continued to spread in 2017, rattling several college campuses across Massachusetts.
Colleges and universities across the country are now facing an existential threat from Covid-19. As institutions with so-called congregate living facilities — close living quarters, crowded classrooms, and communal dining facilities — not to mention a dose of risky social behaviors, administrators across the country shut their doors to students last spring. Many are now deep in efforts to reopen safely. The response of higher ed institutions to the Massachusetts mumps outbreak — in particular, those in Boston, a city of 110 institutions of higher learning and 60 residential colleges — can serve as a blueprint for addressing the current situation with Covid-19.
During and after the mumps outbreaks, our Harvard-based research team worked closely with the Massachusetts Department of Public Health and numerous affected colleges to generate genomic data to characterize the mumps virus, investigate its spread in the area, and develop a plan to keep vulnerable campuses — and the communities around them — safe. We learned six key lessons from this experience that can also be applied to reopening colleges and universities in the time of coronavirus.
Transparency and cooperation are key. Our high-resolution picture of the mumps outbreak could not have been developed if universities had refused to share their data and viral samples. Their cooperation was essential for collecting and integrating the epidemiological and molecular data needed to rapidly investigate the outbreak. The three institutions with the largest numbers of reported cases — Harvard University, Boston University, and the University of Massachusetts, Amherst — all agreed to be named in our study as part of the public health response.
Through careful engagement in the ethical and regulatory process, each contributed data without identifying any affected students.
As champions of open-minded practices and data-sharing, institutions of higher learning have the opportunity to set the standard for transparency and cooperation to seek help and guidance when needed. A safe reopening of any university during the Covid-19 pandemic will require openness and due diligence from everyone, as well as a culture of praising and not shaming institutions that come forward to participate in studies — including those that are sites of super-spreading events.
Keep broader communities safe by keeping college communities safe. Young and more immune-fortified students are often less susceptible to the most severe effects of a disease. But university campuses do not exist in bubbles. When staff members at Harvard contracted mumps and returned home, they unintentionally transmitted the disease into their communities, including the largely unvaccinated and more vulnerable community of East Boston.
Conversations about reopening schools aren’t just about students: They are also about the communities that support and surround them. Including families and communities of all students, staff, and affiliates in response efforts is vital for ensuring the safety of everyone. Inclusion efforts should extend to several degrees of separation to cast the widest net of support for the communities in which colleges exist.
Support should also include regularly engaging with the community to gather feedback and build trust, provide reliable diagnostic and care options, and encourage symptom-reporting and contact-tracing programs that can further enhance community care.
Supplement traditional contact tracing with genome epidemiology. The Massachusetts Department of Public Health and university public health teams performed intensive epidemiological investigations, through which they were able to identify transmission links between cases. Genome sequencing helped confirm the accuracy of these links, but also uncovered many links between cases that would have otherwise been missed.
A telling example: The East Boston outbreak was initially thought to be a distinct event until genome sequencing revealed that the virus detected there was highly similar to those found in a cluster of cases at Harvard. Additional investigation then identified three individuals affiliated with both Harvard and the local community who could have acted as transmission links.
The rapid and often asymptomatic spread of Covid-19 has clearly challenged the capacities of traditional epidemiology. Just as genome sequencing helped increase our understanding of the mumps outbreak, capturing the trajectory of Covid-19 will require the use of newer, complementary technologies. Our recent study of the genomic epidemiology of Covid-19 in Boston uncovered links between a biotech conference in February 2020 and subsequent outbreaks in local homeless shelters and the wider community.
Mobile health applications can enhance epidemiological investigations. Our realization of the limitations of traditional epidemiology during the mumps outbreak led us to build and test mobile apps to allow individuals to report symptoms, confirm diagnoses, and share contacts and other epidemiological data in real-time. We believed this type of approach could gain momentum in a circumscribed, close-knit community where mass adoption can be achieved, much like the launch of Facebook.
We leveraged residential colleges as a relevant demographic that could provide deeper understanding around the value and use of such mobile apps in other densely populated communities. In 2017, when we began surveying students on their use of the apps we were developing, we learned that most students were not well-versed in health monitoring and had widely varying views on privacy. Today, a range of different apps for symptom tracking and contact tracing are available, but data on their widespread use remains scarce.
College campuses provide an opportunity to understand the potential value of mobile health apps in a relatively well-defined and receptive community. Based on our preliminary data, however, we understand that the appropriate and safe use of contact-tracing apps for Covid-19 will require education and engagement of students, as well as further analysis to determine the best and most relevant options for them.
To this end, public health officials and institution leaders must continuously highlight the personal incentives all students have to use these apps and provide feedback so they can help keep themselves and their communities safe.
Decentralize diagnosis of symptomatic patients. The emergence of mumps among nurses at Harvard University Health Services (UHS) showed that hospital and clinic waiting rooms are high-risk settings for infection during an outbreak. As long as students are not in need of urgent care, diagnosis and treatment can be done by sample collection and testing outside of university health service facilities, as well as by bringing back the traditional house call. For a college campus with accessible dorms, this is not only feasible but also convenient, given the availability and willingness of health care staff to bring health services to the students. Other options include telehealth, which can provide safe and reliable opportunities for remote assessment and care of patients, thereby limiting the risks of in-person transmission of Covid-19 or other infectious diseases.
These changes are becoming increasingly possible amid the Covid-19 pandemic, given that it can now be detected in noninvasive samples, such as anterior nasal swabs and saliva, which individuals can collect without professional help or supervision. Efforts towards decentralized sample collection and testing need to take into account different challenges for those who are ill and those without means to access care.
Testing programs need to include other co-circulating viruses. Many infectious diseases exhibit overlapping symptoms, like mumps, the flu, and Covid-19, confounding the accuracy of diagnosis. During the current pandemic, most people who have symptoms that could be Covid-19 don’t actually have it, and a negative test for SARS-CoV-2 doesn’t reveal what is actually making someone sick.
This fall and winter, a potential second wave of Covid-19 may appear alongside new cases of the seasonal flu and colds. It is important to employ a broad differential-diagnosis approach, one that allows for the possibility of multiple causes of an individual’s illness instead of just one. With concerns high and lives on the line, sick people need accurate explanations of their symptoms and effective plans for treatment. University programs should provide testing for a range of diseases and incorporate metagenomic sequencing to diagnose patients whose diagnoses are not readily evident.
Thanks to existing vaccines that blunted the spread and impact of mumps, the Harvard outbreak was far more manageable and less dangerous than the current pandemic. The decisions and challenges facing colleges and universities today are more complicated. But one thing is certain: Any institution that has reopened or intends to reopen must do so with a solid plan built on preparedness, transparency, responsible reporting, and collaboration. The safety of students, faculty, and staff — and the communities that surround them — depends on it.
Pardis Sabeti is a professor of organismic and evolutionary biology and immunology and infectious diseases at Harvard University and a researcher at the Broad Institute of MIT and Harvard. Yolanda Botti-Lodovico is the policy lead in the Sabeti Lab at the Broad Institute of MIT and Harvard.