Impact of school closures on coronavirus outbreaks unclear
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There are not many relevant data on the effectiveness of closing schools during coronavirus outbreaks, according to results from a rapid systematic review published in The Lancet Child & Adolescent Health.
“This finding is perhaps not surprising for the rapidly emerging COVID-19 pandemic, but previous coronavirus outbreaks such as SARS and MERS provide limited information about the effectiveness of school closures and no data on cost-effectiveness,” Russell M. Viner, MBBS, PhD, professor of adolescent health at University College London, and colleagues wrote. “No data on other less disruptive school social distancing practices during coronavirus outbreaks were identified.”
Viner and colleagues pooled 616 articles from numerous databases and included data from 16 in their review: eight from PubMed, six preprint articles, one from a hand search and one non-peer-reviewed modeling study. They excluded opinion pieces, systematic reviews, studies addressing other viruses, studies in university-specific settings, epidemiological studies that did not examine intervention effects and untranslated non-English studies. Nine of the studies were published, and seven were not peer-reviewed.
Nine of the 16 studies dealt with the 2003 SARS outbreak, including all of the published articles. Two were modeling studies. The other seven studies were not peer reviewed — one preprint study dealt with other coronaviruses (229E, NL63, OC43, and HKU1), and the other five preprint studies and one report focused on COVID-19. The authors included the unreviewed studies on COVID-19 because no other data were available.
“Data from the SARS outbreak in mainland China, Hong Kong, and Singapore suggest that school transmission played no substantial role in the outbreak, and that school closures and other activities such as school temperature monitoring did not contribute to control of infection transmission,” Viner and colleagues reported.
Both modeling studies on the 2003 SARS outbreak provided different results. One estimated that school closures were important in reducing transmission, whereas the other estimated that transmission levels in classrooms were low. Closures of schools due to COVID-19 began in mainland China and Hong Kong early this year, but no data were available on the effectiveness of the closures.
“Authors of preprint studies concluded that school closures likely contributed to the control of COVID-19 in China as part of a package of very broad quarantine measures. However, they provide no data to support this assertion,” Viner and colleagues wrote.
They cited a modeling study that used population and school data from the United Kingdom and data on the transmission dynamics of COVID-19 from Wuhan, China, to predict that school closures alone would reduce deaths during a COVID-19 outbreak in the U.K. by 2% to 4%.
Viner and colleagues said evidence to support school closures because of COVID-19 is weak, and data from influenza outbreaks suggest school closures have a small effect. – by Ken Downey Jr.
Disclosures: The authors report no relevant financial disclosures.Perspective
Back to TopC. Buddy Creech, MD, MPH
At the outset, it is important to recognize that for nearly any respiratory virus with widespread community circulation, closing of schools has always been a public health tool available to us to control ongoing spread. The reasons for this are myriad — close interactions between students; children attending school while pre-symptomatic or early in symptoms; and ongoing viral shedding early in recovery. Therefore, it is reasonable to conclude that schools are an easy place for infections to spread, and children may carry these infections to their individual homes.
The primary difference with COVID-19 is that the infection frequency among children appears to be quite different from that in adults — both in terms of the overall burden of disease and the severity of infection. An additional challenge is that we do not know the total burden of asymptomatic transmission, particularly in children, nor do we know the seroprevalence of immunity in the community.
I think these are some of the reasons why school closures have played a role in the U.S. Not only does it remove this unknown variable from consideration, it also serves to protect educators and school staff, who may be exposed to those with mild disease but may develop severe disease themselves. As we learn more, and as we compare our experience to other regions around the world, we may conclude that the closing of schools, summer camps, or other places where kids might gather will no longer be a core community-based intervention that is needed to flatten the curve. Thus, one could hypothesize that as we relax some social distancing and sheltering in place, school closures may be one intervention that is deemed less critical than other maneuvers that have clearly proven to be beneficial. The elephant in the room is that we simply do not know the impact of this approach and the consequences for being wrong are significant. This approach would also require precise communication to avoid confusion — if schools are reopened, but ongoing social distancing is required, careful messaging will be critical.
The data in this report are incredibly valuable as we think about a staged return to typical operations. There may be some environments — like large sporting events, concerts, and other places where thousands of people gather — that will continue to be unwise to be in for a prolonged period of time. There are other activities, however, that may be found to pose less risk to the general population as the pandemic moves forward. These data allow us to understand where school, childcare, summer camps, and other activities where children gather factor into that staged return.
Disclosure: Creech reports no relevant financial disclosures.
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