As governments around the globe deploy a variety of different lockdown strategies to try to contain the spread of COVID-19, one of the most divisive issues is whether or not widespread school closures are a good idea. Unlike other social interventions, such as stopping non-essential services or limiting the size of public gatherings, shutting down schools can result in a profound domino effect through a community, from increasing health-care worker absenteeism to endangering the health and safety of marginalized children.
The vast majority of countries around the world are currently implementing mass school closures as part of greater strategies to suppress this first acute wave of the COVID-19 pandemic. Published in The Lancet Child & Adolescent Health, a new systematic review from an international team of researchers is offering one of the first broad investigations into how effective school closures may be in slowing the spread of infectious disease outbreaks. The study also questions when, and how, schools can reopen in light of what is looking like a pandemic that may last between one and two years.
What effect do school closures have on viral transmission rates?
The new research reviewed 16 studies, trying to answer one big question: “What is known about the use of and effectiveness and cost-effectiveness of school closure and other school social distancing practices on infection rates and transmission during coronavirus outbreaks?”
Nine of the studies reviewed were investigating how effective school closures were during the 2003 SARS outbreak, while the rest were mostly preprint, yet to be peer-reviewed, studies taking early looks at various local responses to COVID-19.
The general conclusion is school closures may not play a significant role in controlling the spread of COVID-19. Russell Viner, from University College London and corresponding author on the new study, says looking at the SARS epidemic, school closures seemed to have little effect on stemming transmission. And, homing in more specifically on our current pandemic, the nature of this novel coronavirus suggests children may not be major drivers of community transmission.
“We know from previous studies that school closures are likely to have the greatest effect if the virus has low transmissibility and attack rates are higher in children,” explains Viner. “This is the opposite of COVID-19. Data on the benefit of school closures in the COVID-19 outbreak is limited but what we know shows that their impact is likely to be only small compared to other infection control measures such as case isolation and is only effective when other social isolating measures are adhered to.”
Neil Ferguson, from Imperial College London’s MRC Centre for Global Infectious Disease Analysis, has been providing some of the most influential COVID-19 modeling over the past couple of months. He disagrees with Viner’s conclusions, suggesting school closures are an important part of greater outbreak control strategies.
“While school closure as a measure on its own is predicted to have a limited effectiveness in controlling COVID-19 transmission, when combined with intense social distancing it plays an important role in severing remaining contacts between households and thus ensuring transmission declines,” says Ferguson. “While this new paper reviews some of the modeling our group undertook of school closure for less intensive mitigation, it did not include our results for school closure in combination with other lockdown measures.”
So, although it seems clear that closing schools can, to some degree, reduce viral transmission as part of an overall strong social lockdown strategy, there is certainly division amongst experts over how significant that reduction actually is. Of course, there are also broader concerns that need to be considered when weighing up whether schools should be closed, and for how long.
The healthcare impact
A new model from a pair of US researchers, published in The Lancet Global Health, explored one highly specific question: From an overall mortality perspective, would closing schools result in more, or less, COVID-19 deaths?
The research set out to calculate what effect school closures would have on absenteeism in healthcare sectors, and whether those labor shortages could increase case fatality rates. So, essentially the question is, do the extra COVID-19 cases that may potentially appear if schools stayed open result in more deaths than would occur if a volume of health care workers dropped out of work due to having to stay at home and take care of children?
The answer is … maybe.
The study found at least one in seven medical workers may have to miss work to care for young children if all schools in the United States were closed. It is unclear exactly what impact this healthcare workforce reduction would have on overall COVID-19 mortality, but, the study does suggest if those fatality rates grew from 2 percent to 2.4 percent due to labor shortages, then that would eliminate any benefit in case reduction load initially gained from closing schools in the first place.
“Health-care workers spending less time providing patient care to look after their own children can directly influence the development of an epidemic and the survival of those patients,” explains co-lead on the research, Eli Fenichel from Yale University. “Understanding these trade-offs is vital when planning the public health response to COVID-19 because if the survival of infected patients is sufficiently sensitive to declines in the healthcare workforce, then school closures could potentially increase deaths from COVID-19.”
Underpinning this entire model is the assumption parents will have no alternative childcare options in the face of mass school closures. Jude Bayham, co-lead on the research with Eli Fenichel, suggests local childcare options from state to state vary across America, but in general the US healthcare system is especially prone to labor shortages, and childcare alternatives must be a significant consideration when authorities make the call to close schools.
“The US healthcare system appears disproportionately prone to labor shortages from school closures, particularly among those health-care workers providing infection control in nursing homes,” says Bayham. “These potential health-care workforce shortages should be a priority when assessing the potential benefits and costs of school closures, and alternative child care arrangements must be part of the school closure plan.”
So schools are closed, now what?
As of early April, over 180 countries around the world had instituted some kind of acute school closures. Over 90 percent of the globe’s student population are affected, comprising more than one and a half billion students.
So it’s not unreasonable to suggest the debate over closing schools is moot. It has already happened … the vast majority of schools around the world have shut.
The question now is when, and how, should schools reopen?
“Countries that have closed schools, such as the UK, have to now ask hard questions about when and how to open schools,” says Russell Viner. “Interventions in schools, such as closing playgrounds, keeping students in constant class groups/classrooms; increasing spacing between students in classes, reducing the school week and staggering school start and break times across years or classes, should be considered, if restrictive social distancing policies are to be implemented for long periods of time.”
In Australia, for example, a country with a federal government that has been very reticent to announce a national school closure, the state of Victoria has forged its own path, announcing schools will open later in April following the traditional Easter holiday break, but they will only be accessible to a very limited number of students.
“As we act to slow the spread of coronavirus, the message to students and parents of government schools is clear: all children who can learn at home must learn from home – with exceptions only in extremely limited circumstances,” a state government announcement notes. “On-site learning will only be available for children whose parents can’t work from home and vulnerable students without access to a suitable learning environment at home.”
This strategy attempts to thread the needle between outright school closure, and a more general reopening. Schools in the Australian state will remain open, but only to students with special needs or with parents in essential services that cannot work from home. It is an ambitious approach, leaning on the majority of parents taking on home-schooling their children, while leaving schools open as a kind of state-run childcare service.
The concern over the impact of long-term school closures on the most vulnerable members of the community is not an abstract worry. A recent correspondence from a pair of University of Nottingham epidemiologists published in The Lancet Global Health points out the worrying long-term risks of deepening social, economic, and health inequities for children through extended school closures.
“School closures during the 2014–16 Ebola epidemic increased dropouts, child labor, violence against children, teen pregnancies, and persisting socioeconomic and gender disparities,” the pair write in the correspondence. “Access to distance learning through digital technologies is highly unequal, and subsidized meal programs, vaccination clinics, and school nurses are essential to child health care, especially for marginalized communities. Schools provide safeguarding and supervision, and closures increase the economic burden of families using day care or their reliance on vulnerable older relatives. Working parents might leave children unsupervised or forgo employment to stay at home with them.”
Watch and wait
At a recent press briefing, Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said schools will most likely have to remain closed in the United States until the new school year begins in fall. Considering the current school year was almost complete, this is not a profound disruption to the educational calendar, but Fauci does note if schools reopen in late August or early September they will look quite different to how they used to look, with broad distancing strategies and testing protocols in place to prevent a resurgence of the virus.
Ultimately, no one really knows how this will all play out over the coming months. Every country’s situation is unique, and everyone is watching each other to see what is working and what is failing.
Denmark has already announced it is reopening some schools as early as next week. Taiwan, on the other hand, managed to stem the initial spread of the virus without closing schools, but will a second wave of COVID-19 result in a nation-wide school shutdown?
Will Australia see a case load spike that forces a more stringent nation-wide school shutdown later in April? Will China’s gradual reopening of schools continue without a second wave of transmission? And how long can countries realistically keep schools closed before significant social problems arise?
“With nearly 90 percent of the world’s students (more than a billion and a half of young people) out of school, more data and robust modeling studies are urgently needed to help us identify how countries can, in time, safely return students to education,” concludes Viner.
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