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What are the independent associations of voluntary behavioral change and legal restrictions, such as state-mandated school closings, with the subsequent spread of the coronavirus disease 2019 (COVID-19) pandemic in the US?
In this cross-sectional study of US COVID-19 data, voluntary behavioral changes, such as reductions in time spent at work, had an association with reduced COVID-19 incidence and mortality that was 3 times stronger than that of school closures.
These findings suggest that less harmful ways of preventing severe acute respiratory syndrome coronavirus 2 transmission are available than mandatory school closures.
The consequences of school closures for children’s health are profound, but existing evidence on their effectiveness in limiting severe acute respiratory syndrome coronavirus 2 transmission is unsettled.
To determine the independent associations of voluntary behavioral change, school closures, and bans on large gatherings with the incidence and mortality due to coronavirus disease 2019 (COVID-19).
Design, Setting, and Participants
This population-based, interrupted-time-series analysis of lagged independent variables used publicly available observational data from US states during a 60-day period from March 8 to May 18, 2020. The behavioral measures were collected from anonymized cell phone or internet data for individuals in the US and compared with a baseline of January 3 to February 6, 2020. Estimates were also controlled for several state-level characteristics.
Days since school closure, days since a ban on gatherings of 10 or more people, and days since residents voluntarily conducted a 15% or more decline in time spent at work via Google Mobility data.
Main Outcomes and Measures
The natural log of 7-day mean COVID-19 incidence and mortality.
During the study period, the rate of restaurant dining declined from 1 year earlier by a mean (SD) of 98.3% (5.2%) during the study period. Time at work declined by a mean (SD) of 40.0% (7.9%); time at home increased by a mean (SD) of 15.4% (3.7%). In fully adjusted models, an advance of 1 day in implementing mandatory school closures was associated with a 3.5% reduction (incidence rate ratio [IRR], 0.965; 95% CI, 0.946-0.984) in incidence, whereas each day earlier that behavioral change occurred was associated with a 9.3% reduction (IRR, 0.907; 95% CI, 0.890-0.925) in incidence. For mortality, each day earlier that school closures occurred was associated with a subsequent 3.8% reduction (IRR, 0.962; 95% CI, 0.926-0.998), and each day of advance in behavioral change was associated with a 9.8% reduction (IRR, 0.902; 95% CI, 0.869-0.936). Simulations suggest that a 2-week delay in school closures alone would have been associated with an additional 23 000 (95% CI, 2000-62 000) deaths, whereas a 2-week delay in voluntary behavioral change with school closures remaining the same would have been associated with an additional 140 000 (95% CI, 65 000-294 000) deaths.
Conclusions and Relevance
In light of the harm to children of closing schools, these findings suggest that policy makers should consider better leveraging the public’s willingness to protect itself through voluntary behavioral change.
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Accepted for Publication: November 18, 2020.
Published Online: February 22, 2021. doi:10.1001/jamapediatrics.2020.6371
Corresponding Author: Frederick J. Zimmerman, PhD, Center for Health Advancement, Department of Health Policy and Management, Fielding School of Public Health at UCLA, PO Box 951772, Los Angeles, CA 90095-1772 (firstname.lastname@example.org).
Correction: This article was corrected on March 8, 2021, to fix errors and add clarification in the Abstract, main text, and Table.
Author Contributions: Dr Zimmerman and Mr Anderson had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the UCLA Clinical and Translational Science Institute grant TL1TR001883 from the National Institutes of Health/National Center for Advancing Translational Science (Mr Anderson).
Role of the Funder/Sponsor: The funders 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.
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