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School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, IrelandScience Foundation Ireland FutureNeuro Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
Department of Clinical Microbiology, RCSI University of Medicine and Healthcare Sciences, Dublin, IrelandDepartment of Microbiology, Beaumont Hospital, Dublin, Ireland
Corresponding author. Address: Department of Clinical Microbiology, RCSI Education and Research Centre, Beaumont Hospital, Dublin D09 YD60, Ireland. Tel.: +35387 2865424.
]. Medical undergraduate education involves significant in-person training, so there is a need for policies to prevent onward transmission to students, healthcare workers (HCWs) and patients [
The Royal College of Surgeons in Ireland (RCSI) University of Medicine & Health Sciences developed a student-centred, holistic approach to students' educational, social and health needs in Dublin. During the pandemic, there were 1942 enrolled medical students, over 80% of whom travel to Ireland from approximately 90 countries. Students mainly live in Dublin in self-contained rented housing. Students were re-arranged into distinct learning communities, and required to record their COVID-19 symptom status each day using a university-developed online app.
Given the huge pressure on public and private health systems, RCSI established an on-campus laboratory testing facility. The Senior Management Team established a multi-disciplinary Laboratory Governance Group to ensure alignment with hospital infection prevention and control (IPC) and Irish Health Service Executive (HSE) public health pathways. All positive results were notified to HSE. This article describes the establishment of in-house student testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (largely for asymptomatic carriage) in order to safeguard students, staff, HCWs and patients, while other measures were in place to prevent infection in patients and HCWs in clinical settings.
Medical students were tested at the start of the semester and before clinical placements from November 2020 until February 2022. Following confirmation in October 2021 that the SalivaDirect method was a valuable alternative to nasopharyngeal swabs, this was used for COVID-19 testing [
]. Testing with nasopharyngeal swabs was based on the protocol of the US Centers for Disease Control and Prevention, while saliva testing was based on the SalivaDirect method [
]. All positive results were confirmed by retesting with the TaqPath COVID-19 CE-IVD reverse transcription polymerase chain reaction kit.
In total, 20,046 and 1962 samples were processed for asymptomatic screening and symptomatic diagnosis, respectively. Of 173 (0.79%) positive results, 39 (22%) were nasopharyngeal swab samples and the remainder were saliva samples. One hundred and seven (62%) positive results were detected from asymptomatic students. In total, 35% (25/66) of the positive results from the symptomatic cohort had cycle threshold (Ct) values ≤25, compared with 10% (11/107) for asymptomatic students.
Genotyping was undertaken to determine if SARS-CoV-2 variants mirrored those in the community, given the international nature of the student cohort. Whole-genome sequencing (WGS) was performed at an external laboratory (Teagasc, Cork, Ireland) on selected samples with a Ct value <30. Similar to the general population, the Alpha variant was first detected in early January 2021, and the Delta variant dominated the last quarter of 2021 until the Omicron variant emerged in early 2022 (Figure 1).
Figure 1Pattern of genotypes detected from Royal College of Surgeons in Ireland students, November 2020–February 2022.
In parallel with laboratory-based testing, the RCSI general practitioner practice expanded to provide a 7-day primary care COVID-19 service. Positive students were tested by HSE to ensure that their results were recorded in the national database. There were 10,000 COVID-19-related consultations, with 673 student positives from in-house and external testing (i.e. symptomatic students presenting to HSE testing sites). Easily accessible information was achieved by upgrading and expanding the website www.mercersmedicalcentre.com, with 55,000 visits between September 2020 and August 2021. Of 144 medical students identified as close contacts, seven tested positive but with no circumstantial or laboratory evidence of transmission to patients or staff.
There is no completely risk-free way to re-open a university campus, but measures such as wearing masks, social distancing, vaccination, education, implementation of IPC measures, and testing and tracing help [
]. Specifically, IPC measures include students and staff absenting themselves from classes if they are symptomatic or have been in close contact with a COVID-19 case, engineering controls to avoid the recirculation of contaminated air, and use of personal protective equipment (PPE) [
]. It is also essential that measures, such as patient isolation and use of PPE, are in place in clinical settings in order to prevent the acquisition and spread of COVID-19 amongst patients, HCWs and any students on placements.
When testing was first commenced, antigen testing was not widely available, but even subsequently, molecular testing was preferred to detect SARS-CoV-2 in the asymptomatic and the pre-symptomatic phases [
Sensitivity of rapid antigen testing and RT-PCR performed on nasopharyngeal swabs versus saliva samples in COVID-19 hospitalised patients: results of a prospective comparative trial (RESTART).
]. At Bristol University, UK, only one in 10 students had the recommended two lateral flow antigen tests, with barriers being a lack of awareness and understanding, and concerns about accuracy and safety [
]. The student engagement found in the study reported here may be, in part due to a greater awareness of IPC amongst medical students.
The absence of identifiable spread during clinical placements reassured hospital senior management. Governance overseeing laboratory testing, clinical liaison to follow-up positive students, and the involvement of consultant microbiologists with joint clinical and academic posts were important. Accurate and effective laboratory methods aligned with routine accredited diagnostic laboratories were also critical, including confirmation that the use of saliva samples was as appropriate as the use of nasopharyngeal swabs [
]. Medical students recognize their increasing needs for IPC education, including the use of simulation, increased instruction on the use of PPE, and being directed to reputable sources [
]. In the event of further pandemics or large epidemics, a holistic approach with laboratory testing (including on-campus) will be important for control.
Acknowledgements
The authors wish to acknowledge the contribution and leadership of the RCSI Students' Unions and other student volunteers, and all RCSI staff for their commitment, dedication and professionalism during this most challenging of times. In addition, the authors acknowledge the help of all staff in hospitals. Finally, the authors wish to thank their colleagues at Teagasc, Cork, Ireland, specifically Drs Paul Cotter and Fiona Crispie for sequencing.
Author contributions
All authors were members of the RCSI COVID-19 Laboratory Governance Group or the RCSI management team in Dublin managing the pandemic, and reviewed drafts and agreed the final version. CdeS delivered and supervised the laboratory testing. GC and SK provided significant molecular and scientific oversight and input. KG and VQ managed COVID-19-positive students. RB, JG and KB liaised with RCSI senior management. FF and HH liaised with clinical sites. HH wrote the first draft of this manuscript.
Conflict of interest statement
None declared.
Funding source
RCSI funded the laboratory testing for SARS-CoV-2 as part of its overall strategy. All the authors contributed as part of their other professional and academic activities.
Ethical approval
An initial submission to the RCSI Ethics Committee was not possible, given the need to act quickly and effectively, but students individually and collectively agreed to testing, as described. However, written consent was obtained from the RCSI Ethics Committee to compare nasopharyngeal swab testing with saliva testing.
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