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Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US

Educational Objective
To understand the association between statewide school closure and COVID-19 incident and mortality
1 Credit CME
Key Points

Question  Was statewide school closure associated with decreased incidence and mortality for coronavirus disease 2019 (COVID-19)?

Findings  In this US population–based time series analysis conducted between March 9, 2020, and May 7, 2020, school closure was associated with a significant decline in both incidence of COVID-19 (adjusted relative change per week, −62%) and mortality (adjusted relative change per week, −58%). In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

Meaning  There was a temporal association between statewide school closure and lower COVID-19 incidence and mortality, although some of the reductions may have been related to other concurrent nonpharmaceutical interventions.

Abstract

Importance  In the US, states enacted nonpharmaceutical interventions, including school closure, to reduce the spread of coronavirus disease 2019 (COVID-19). All 50 states closed schools in March 2020 despite uncertainty if school closure would be effective.

Objective  To determine if school closure and its timing were associated with decreased COVID-19 incidence and mortality.

Design, Setting, and Participants  US population–based observational study conducted between March 9, 2020, and May 7, 2020, using interrupted time series analyses incorporating a lag period to allow for potential policy-associated changes to occur. To isolate the association of school closure with outcomes, state-level nonpharmaceutical interventions and attributes were included in negative binomial regression models. States were examined in quartiles based on state-level COVID-19 cumulative incidence per 100 000 residents at the time of school closure. Models were used to derive the estimated absolute differences between schools that closed and schools that remained open as well as the number of cases and deaths if states had closed schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile.

Exposures  Closure of primary and secondary schools.

Main Outcomes and Measures  COVID-19 daily incidence and mortality per 100 000 residents.

Results  COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100 000 population. School closure was associated with a significant decline in the incidence of COVID-19 (adjusted relative change per week, −62% [95% CI, −71% to −49%]) and mortality (adjusted relative change per week, −58% [95% CI, −68% to −46%]). Both of these associations were largest in states with low cumulative incidence of COVID-19 at the time of school closure. For example, states with the lowest incidence of COVID-19 had a −72% (95% CI, −79% to −62%) relative change in incidence compared with −49% (95% CI, −62% to −33%) for those states with the highest cumulative incidence. In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

Conclusions and Relevance  Between March 9, 2020, and May 7, 2020, school closure in the US was temporally associated with decreased COVID-19 incidence and mortality; states that closed schools earlier, when cumulative incidence of COVID-19 was low, had the largest relative reduction in incidence and mortality. However, it remains possible that some of the reduction may have been related to other concurrent nonpharmaceutical interventions.

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Article Information

Corresponding Author: Katherine A. Auger, MD, MSc, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML 9016, Cincinnati, OH 45229 (katherine.auger@cchmc.org).

Accepted for Publication: July 17, 2020.

Published Online: July 29, 2020. doi:10.1001/jama.2020.14348

Author Contributions: Dr Richardson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Brady, Schondelmeyer, and Thomson made equal substantial contributions to the manuscript and are co-last authors.

Concept and design: Auger, Shah, Richardson, Hartley, Hall, Warniment, Bosse, Ferris, Brady, Schondelmeyer, Thomson.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Auger, Richardson, Timmons, Brady, Schondelmeyer.

Critical revision of the manuscript for important intellectual content: Shah, Richardson, Hartley, Hall, Warniment, Bosse, Ferris, Brady, Schondelmeyer, Thomson.

Statistical analysis: Auger, Richardson, Hartley, Hall.

Administrative, technical, or material support: Hartley, Warniment, Timmons, Bosse, Ferris, Thomson.

Supervision: Brady, Schondelmeyer, Thomson.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding for this work was provided by Agency for Healthcare Research and Quality awards K08HS024735 (Dr Auger), K08HS023827 (Dr Brady), K08HS026763 (Dr Schondelmeyer), and K08HS025138 (Dr Thomson) and award 5UL1TR001425-04 from the National Center for Advancing Translational Sciences, National Institutes of Health.

Role of the Funder/Sponsor: The Agency for Healthcare Research and Quality and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not represent the official views of the Agency for Healthcare Research and Quality, the National Institutes of Health, Cincinnati Children’s Hospital Medical Center, the Children’s Hospital Association, or the Pediatric Research in Inpatient Settings Network.

Additional Information: Drs Richardson and Hall are affiliated with the Children’s Hospital Association, Lenexa, Kansas.

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