Abstract
In the summer of 2020, SARS-CoV-2 infection rates among the U.S. population aged 20–39 years exceeded other age groups, with the largest increases occurring in the southern US. As many colleges reopened for in-person instruction in August and September, these trends continued among campuses across the country. Our study aimed to identify risk factors (demographic and behavioral) associated with SARS-CoV-2 infection among college students. We used data from a survey administered to students at a southern university in the US. The survey had a total of 765 respondents and this study included the 679 (88.8%) who responded about their SARS-CoV-2 infection status. We examined associations between population characteristics and reported SARS-CoV-2 infection and calculated prevalence ratios along with 95% confidence intervals. SARS-CoV-2 infection was 2.5 times more likely among current users of electronic nicotine delivery systems (ENDS) compared to those who do not use ENDS (95% confidence interval [CI]: (1.76–3.4)) and 2.8 times more likely among those who reported a high frequency of binge drinking compared to those who did not report binge drinking (95% CI: (1.81–4.36)). Current high frequency ENDS users were 2.76 (1.79–4.25) more likely to report SARS-CoV-2 infection than non-users. Current low frequency users of ENDS were 2.27 (1.53–3.37) times more likely to report SARS-CoV-2 infection than nonusers. A trend analysis among ENDS use frequency and SARS-CoV-2 infection was statistically significant, showing a significant dose response with increasing ENDS use. The results of this analysis may assist in providing guidance on policies as well as may serve as a steppingstone for future research concerning SAR-CoV-2 infection among university populations.
Introduction
In the summer of 2020, SARS-CoV-2 infection rates among young adults in the US exceeded other age groups, with the largest increases occurring in the southern US.Citation1 As many colleges reopened in the Fall of 2020, these increases continued among campuses across the country.Citation2
University lifestyles may present many risks for SARS-CoV-2 transmission including congregate living quarters settings (e.g., dorms, apartments, and fraternity/sorority houses), social gatherings, and the necessity to access many services in public settings (e.g., libraries, dining halls, and student unions). Individually, each aspect can impose heightened risk and, together, they may augment contact rates and the transmissibility of SARS-CoV-2 and other respiratory pathogens. Furthermore, these lifestyle features characteristic to the university setting can pose non-trivial challenges to programs to reduce transmission in college towns and neighboring communities.Citation3
While most students are in age groups who are less likely to experience severe infection, hospitalization, or death, they interact with professors, staff, administrators, and community members who are at a higher risk for severe disease. This combination may result in infection rates on campus that may pose a risk to people in the community and its surrounding areas.Citation4–6 Given the increased transmission reported in colleges, it is important to examine demographic and behavioral factors that associate with SARS-CoV-2 infection among college populations.
Using data from a survey administered to students at a southern university in the US, our study aims to identify students’ characteristics (demographic and behavioral) associated with SARS-CoV-2 infection among college students. The results of our study could aid universities in tailoring prevention and control strategies in the coming months and years as they continue to manage the pandemic.
Methods
Data for this study was obtained from an online health survey that obtained a convenience sample of students enrolled at the university during the fall semester, 2020. The survey was reviewed and approved by the university’s institutional review board, collected online and distributed to students by program administrators from each individual college within the university. The survey included students’ demographics and academic characteristics, students’ health habits, including ENDS use, cigarette smoking, alcohol consumption, exercise intensity and duration, and influenza vaccination, as well as SARS-CoV-2 infection occurrence and opinion regarding the effectiveness of mask use for stopping the spread of SARS-CoV-2.
For this brief report, SARS-CoV-2 infection was considered the primary outcome of interest. SARS-CoV-2 infection status was based on self-reported in response to the survey question, “Have you ever been infected with SARS-CoV-2 or had COVID-19?” Respondents were categorized as having had a SARS-CoV-2 infection if they answered, “Yes, my diagnosis was confirmed with a positive laboratory test (either symptomatic or asymptomatic)” or “Yes, I experienced symptoms, but my diagnosis was not laboratory confirmed.” Respondents who did not provide information on SARS-CoV-2 infection were removed before the primary analysis.
The demographic covariates we examined included biological sex, age in years, and race/ethnicity. Due to low cell counts among Asian (non-Hispanic), Black or African American (non-Hispanic), Multi/other (Non-Hispanic), and Hispanic participants, we categorized race/ethnicity as white (non-Hispanic) and other races combined. Academic characteristics included level of study (graduate or undergraduate), housing (on campus dorms or off-campus housing), and cumulative grade point average. ENDS use and cigarette smoking questions ascertained current use (yes or no), frequency of current use, and maximum frequency of previous use. Participants were categorized as “high” frequency ENDS users if they reported using ENDS 2–3 times a week or more and “low” if they reported less. Respondents’ alcohol consumption was categorized into high binge drinking, low binge drinking, or never based on CDC’s standard binge drinking definitions for males and females. For males, this is defined as consuming five or more alcoholic beverages in a two-hour period and for females, 4 or more in a two-hour period.Citation7 High binge drinking occurrence was defined as 2 to 16 times and month, and low was defined as 1 to 11 times in the past year. Respondents’ exercise habits were categorized based on responses to weekly frequency and duration of moderate and vigorous-intensity exercise. Exercise frequency was coded based on recommendations by the US Department of Health and Human Services (HHS).Citation8 Respondents were categorized as less than 150 minutes per week, 150–299 minutes per week, or 300 or more minutes per week.
Our analysis presents univariate frequencies and bivariate comparisons. In order to assess associations between covariates and SARS-CoV-2 infection, prevalence ratios were calculated along with 95% confidence intervals. Cochran Armitage trends tests were conducted for multi-level variables (frequency of ENDS use) to assess possible dose response about the outcome. All data cleaning and analysis were performed in R Studio Version 1.1.453.
Results
The survey had a total of 765 respondents and this study included the 679 (88.8%) who provided information on SARS-CoV-2 infection. The prevalence of SARS-CoV-2 infection within our sample was 16.9% (n = 115). Twenty-nine percent of study population were age 20–21. The majority were female (78.6%), non-Hispanic White (79.7%), undergraduate (55.7%), and living in off-campus housing (79.8%). One hundred twenty-five (18.4%) participants reported current use of ENDS and 46 (6.8%) reported current high-frequency use (i.e., from 2 to 3 times a week up to multiple times per day). One hundred and three (15.2%) reported previous use of ENDS (at maximum) in the high frequency category. Sixty-eight (10.0%) participants reported currently smoking cigarettes and 6 (0.9%) reported currently smoking in the high frequency category (i.e., from 2 to 3 times a week up to multiple times per day). Fifty-nine (8.7%) reported previous cigarette smoking in the high frequency category. The majority of individuals reported some binge drinking behavior: 125 participants (18.4%) in the high frequency category and 317 (46.7%) in the low frequency category. Among the individuals in this investigation, 291 (42.9%) reported 300 minutes or more of moderate-intensity physical activity per week and 148 (21.8%) reporting between 150 and 299 minutes of moderate-intensity physical activity per week. Fifty-six percent (n = 383) reported having a current influenza vaccine. Most participants in the study (90.4%) reported that they believed mask use protects against SARS-CoV-2 infection. These results are displayed in .
Table 1. Demographic and behavioral risk factors and COVID-19, Southern US University, 2020.
The prevalence of SARS-CoV-2 infection was significantly higher among females versus males, undergraduate vs graduate students, and those living in on-campus dorms vs off campus housing. Respondents aged 18 to 19 years were 3.99 (2.08–7.66) times more likely report SARS-CoV-2 compared to those age 26 and up. This relationship was similar for the age 20 to 21 group compared with to those age 26 and up. The prevalence of SARS-CoV-2 was 2.71 (1.41–5.21) times higher among White (non-Hispanic) students when compared with all other races combined (Asian, Black, Hispanic, and Multi/other).
The prevalence of SARS-CoV-2 infection was 1.5 (1.02–2.34) times higher among students who exercise more than 300 minutes per week compared with students who exercise less than 150 minutes per week. Students who exercise 150–299 minutes per week were 1.7 (1.04–2.64) times more likely to report SARS-CoV-2 compared with students who exercise less than 150 minutes per week.
Those who were current users of ENDS were 2.45 (1.76–3.4) times more likely to report SARS-CoV-2 infection compared to those who do not currently use ENDS. Further, current high frequency users of ENDS were 2.76 (1.79–4.25) more likely to report SARS-CoV-2 infection than those who do not currently use ENDS and current low frequency users of ENDS were 2.27 (1.53–3.37) times more likely to report SARS-CoV-2 infection vs those who do not currently use ENDS. The Cochran Armitage test for trend among ENDS use frequency and SARS-CoV-2 infection had a p-value of <0.0001, indicating a statistically significant dose response with increasing ENDS use. Those who reported a high frequency of binge drinking were 2.80 (1.81–4.36) times more likely to have reported SARS-CoV-2 infection compared to those who did not binge drink. There was not a statistically significant relationship between low frequency binge drinking and SARS-CoV-2 infection. Regarding smoking cigarettes, there was no significant association between current or previous cigarette smoking and SARS-CoV-2 infection.
Discussion
This analysis reveals significant associations between several demographic and behavioral risk factors among college students and SARS-CoV-2. Among our study population we found elevated risk of SARS-COV-2 infection among non-Hispanic Whites, females and undergraduate students, as well as associations with binge drinking and ENDS use. The results of this analysis may assist in providing guidance on policies as well as may serve as a steppingstone for future research.
These findings are consistent with a large (n = 4,351), national cross-sectional study that found an increased risk for COVID-19 diagnosis among current users of ENDS in the 13–24 age group.Citation9 An ecological study published December of 2020 also found that statewide vaping prevalence was significantly associated with both COVID-19 cases and deaths on a state level.Citation10 Our study data is not sufficient to examine any possible biological mechanisms that increase the risk of SARS-CoV-2 infection among those who use of ENDS or binge drink frequently, but previous studies suggest that electronic-cigarette use can change the nasal mucosal immune response to other viruses such as influenza.Citation11
We found an association between ENDS and binge drinking with risk for SARS-CoV-2 infection. The reasons for this association need to be explored and may include differences in following COVID-19 recommendations, greater potential of exposure to infected persons, or other factors. A large study conducted in the UK found that those who reported following COVID-19 protective behaviors were negatively associated with increased alcohol consumption.Citation12 Further, people who use ENDS while in a group might be likely to share devices, which could lead to higher transmission, but the data in our analysis does not include information on participants sharing ENDS. Regarding drinking, studies have shown that sharing glasses when drinking alcohol can increase the risk of SARS-CoV-2 infection.Citation13
The results of the study also show that undergraduate students were 1.9 (1.31–2.75) times more likely to report SARS-CoV-2 compared with graduate students. Undergraduates tend to live with more roommates in dorms and apartments as compared to graduate students and engage in more social events. Undergraduate students also attend larger classrooms than graduate students. In the study population, the prevalence of SARS-CoV-2 was higher among those who exercised compared with those who do not. A possible explanation for this finding is that higher transmission may occur in gyms. This explanation assumes that students in this study generally exercise in gyms, but the study data does not provide information of location of exercise. A study by Jang et al. examined the transmission of SARS-CoV-2 in fitness centers following an outbreak in South Korea that originated from dance class facilities.Citation14 The investigators suggested that intense exercise in the crowded, warm-air environment of fitness centers may have led to this outbreak due to the resulting denser air droplets, promoting amplified transmission of the virus.Citation14 However, there remains a lack of literature on this subject, and further studies should be conducted to examine possible increase in risk of infection among those who exercise at gyms.
The results of this study found a higher prevalence of SARS-CoV-2 infection among females versus males (PR = 1.74; 95% CI: 1.04, 2.89). One possible explanation for this finding is that women might be more likely than men to get tested if they believe they are experiencing symptoms of COVID-19 or have been exposed to individuals with the virus, although our study did not provide this data. Studies have found that women are more likely than men to perceive COVID-19 as a serious health problem, with men more likely to downplay the virus’ potential to harm them.Citation15 Females have also been found to be more likely than males to comply with public health mitigation protocols, such as imposing self-quarantine at home.Citation15 These factors could have contributed to the higher percentage of females reporting SARS-CoV-2 infection in our study, although there have been no studies that directly address the question of whether women seek out testing more often than men.
There are a few limitations to this study. First, data used for the study was obtained using a convenience sampling approach from the university’s student body and varied from the college’s overall population regarding race, gender, college/major, and year in school. Therefore, it is likely that our sample may not be representative of the population. Second, participants were categorized as having SARS-CoV-2 infection if they reported a positive test or if they experienced symptoms and self-diagnosed. Some of our participants who self-diagnosed might have misdiagnosed themselves with SARS-CoV-2 infection.
Disclosure statement
The authors have no competing interests to disclose. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States of America and received approval from the Institutional Review Board of the University of Georgia.
Funding
No funding was used to support this research and/or the preparation of the manuscript.
References
- Boehmer TK, DeVies J, Caruso E, et al. Changing age distribution of the COVID-19 pandemic—United States, May-August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(39):1404–1409. doi:10.15585/mmwr.mm6939e1.
- Wilson E, Donovan CV, Campbell M, et al. Multiple COVID-19 clusters on a university campus—North Carolina, August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(39):1416–1418. doi:10.15585/mmwr.mm6939e3.
- Teran RA, Ghinai I, Gretsch S, et al. COVID-19 outbreak among a university’s men’s and women’s soccer teams—Chicago, Illinois, July-August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(43):1591–1594. doi:10.15585/mmwr.mm6943e5.
- Liu W, Tao ZW, Wang L, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J (Engl). 2020;133(9):1032–1038. doi:10.1097/CM9.0000000000000775.
- Liu Y, Mao B, Liang S, et al. Association between age and clinical characteristics and outcomes of COVID-19. Eur Respir J. 2020;55(5):2001112. doi:10.1183/13993003.01112-2020.
- Walke HT, Honein MA, Redfield RR. Preventing and responding to COVID-19 on college campuses. JAMA 2020;324(17):1727–1728. doi:10.1001/jama.2020.20027.
- Valencia Martín JL, Galán I, Segura García L, Camarelles Guillem F, Suárez Cardona M, Brime Beteta B. Binge drinking: the challenges of definition and its impact on health. Rev Esp Salud Publ. 2020;94:e202011170.
- U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services; 2018.
- Gaiha SM, Cheng J, Halpern-Felsher B. Association between youth smoking, electronic cigarette use, and COVID-19. J Adolesc Health. 2020;67(4):519–523. doi:10.1016/j.jadohealth.2020.07.002.
- Li D, Croft DP, Ossip DJ, Xie Z. The association between statewide vaping prevalence and COVID-19. Prev Med Rep. 2020;20:101254. doi:10.1016/j.pmedr.2020.101254.
- Rebuli ME, Glista-Baker E, Hoffman JR, et al. Electronic-cigarette use alters nasal mucosal immune response to live-attenuated influenza virus. A clinical trial. Am J Respir Cell Mol Biol. 2021;64(1):126–137. doi:10.1165/rcmb.2020-0164OC.
- Garnett C, Jackson S, Oldham M, Brown J, Steptoe A, Fancourt D. Factors associated with drinking behaviour during COVID-19 social distancing and lockdown among adults in the UK. Drug Alcohol Depend. 2021;219:108461. doi:10.1016/j.drugalcdep.2020.108461.
- Mungmungpuntipantip R, Wiwanitkit V. Sharing alcoholic drinks and a COVID-19 outbreak. Alcohol Alcohol. 2020;55(4):343–343. doi:10.1093/alcalc/agaa028.
- Jang S, Han SH, Rhee J-Y. Cluster of coronavirus disease associated with fitness dance classes, South Korea. Emerg Infect Dis. 2020;26(8):1917–1920. doi:10.3201/eid2608.200633.
- Galasso V, Pons V, Profeta P, Becher M, Brouard S, Foucault M. Gender differences in COVID-19 attitudes and behavior: panel evidence from eight countries. Proc Natl Acad Sci USA. 2020;117(44):27285–27291. doi:10.1073/pnas.2012520117.