Should US schools close to thwart spread of COVID-19?

By Dr. Ananya Mandal, MDApr 6 2020

As of today, the 6^th of April 2020, 364,723 Americans have been infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19 disease. There have been 10,781 deaths due to the infection, as the nation faces difficulty implementing a comprehensive nationwide lockdown to ensure social distancing.

SARS-CoV-2 has infected persons in over 200 countries and territories and was declared a global pandemic on the 11^th of March 2020 by the World Health Organization (WHO). Researchers and epidemiologists across the world have advocated social distancing as an effective method to prevent the spread of this highly infective virus from person to person.

Whilst the US is advocating social distancing, it is still weighing up the difficult choice of closing schools nationwide to prevent transmission from one person to another or keeping them open, so healthcare workers are not stuck at home caring for their children.

A "closed" sign outside of a public school in Grand Rapids, Michigan. The state closed all schools in March 2020 to thwart the spread of the novel coronavirus. Image Credit: Ayman Haykal / Shutterstock

The study

A new study used mathematical modeling to explore the benefits and risks of closing down the schools to prevent new cases and the possibility of absenteeism among health care workers because they need to care for their children at home and the ultimate effect of the step on reducing the risk of deaths due to COVID-19. The study titled, “Impact of school closures for COVID-19 on the US healthcare workforce and net mortality: a modeling study” was published in the latest issue of The Lancet Public Health journal.

The team writes at the outset that it is clear that mandatory closures of the schools could reduce the number of new cases and thus reduce the risk of deaths due to infectious diseases such as influenza and other respiratory viruses. They add that these early studies, however, have never considered the effect of these school closures on the “healthcare labor force.” This study, they wrote, was to assess the “potential benefits from school closures” weighed against “costs of healthcare worker absenteeism associated with additional childcare obligations.” The researchers added that they also assessed the importance of the “contribution of healthcare workers would have to be in reducing mortality for their absenteeism due to childcare obligations to undo the benefits of school closures in reducing the number of cases.”

What was done?

The researchers looked at data from the US Current Population Survey to see the dynamics of the families in the country and the child care options of the health care providers in the US. From there, they identified the portion of healthcare workers who are most obliged with child care needs when the schools are closed. They write that from these numbers, they tried to “identify the critical level at which the importance of healthcare labor supply in increasing the survival probability of a patient with COVID-19 would undo the benefits of school closures and ultimately increase cumulative mortality.”

What did they find?

In the study, researchers analyzed data on more than 3 million individuals between January 2018 and January 2020 to assess the family structure and probable within-household childcare options for healthcare workers. They identified those most likely to require additional childcare for children aged 3-12 years old in the event of school closures by type of healthcare occupation nationally and across different states, assuming that early childcare for children aged under two years remains open. They found that 28.8 percent of the healthcare workforce needed to provide child care to their children aged 3 to 12 years. They wrote, “…the US healthcare sector has some of the highest childcare obligations in the USA”. They assumed that presence of an older sibling over the age of 13 years or a non-working adult at home and still found 15 percent of the healthcare workforce needed to be a home to provide childcare if schools were closed.

Looking at the different workforce in the healthcare sector they noted that 22 percent of nursing personnel, 21 percent of the physician’s assistants, 19 percent of the diagnostic technicians, 13 percent of the nursing and home health care force who are single parents and help care for elderly in nursing homes and 16 percent of physicians and surgeons would find it difficult to arrange for alternative child care options in case of school closure. Childcare needs in case of school closure were highest in each of South Dakota, Oregon, and Missouri at 21 percent, they wrote.

Within the health care system, they found that a 15 percent case reduction in COVID-19 could be seen from school closings, and this would cause a 2 percent reduction in death rates. However, in the hypothetical scenario (where a non-working adult or older sibling looked after the dependent children at home when schools were closed), a 15 percent decreased healthcare workforce would reduce the survival probability per health care provider by 17.6 percent.

They wrote, “Our model estimates that if the infection mortality rate of COVID-19 increases from 2·00% to 2·35% when the healthcare workforce declines by 15·0%, school closures could lead to a greater number of deaths than they prevent.”

Conclusions and implications

Professor Eli Fenichel from Yale University in the USA who co-led the research said, “Closing schools comes with many trade-offs, and can create unintentional childcare shortages that put a strain on the healthcare system. Healthcare workers spending less time providing patient care to look after their children can directly influence the development of an epidemic and the survival of those patients. 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.”

Co-lead author Dr. Jude Bayham from Colorado State University, USA said in his statement, “The US healthcare system appears disproportionately prone to labor shortages from school closures, particularly among those healthcare workers providing infection control in nursing homes. These potential healthcare 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.” Fenichel added, “Closing schools and distancing, in general, is about bending the curve to stay below hospital capacity and reduce COVID-19 mortality, but how we distance to bend the curve can also influence the hospital capacity we need to stay below. We need to account for both.”

The authors of the study concluded that closure of the schools could be beneficial in reducing the number of cases but would increase “unintended childcare obligations.” They suggest, “…potential contagion prevention from school closures needs to be carefully weighted with the potential loss of healthcare workers from the standpoint of reducing cumulative mortality due to COVID-19, in the absence of mitigating measures.”