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Association of the Timing of School Closings and Behavioral Changes With the Evolution of the Coronavirus Disease 2019 Pandemic in the US

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  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?

Findings  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.

Meaning  These findings suggest that less harmful ways of preventing severe acute respiratory syndrome coronavirus 2 transmission are available than mandatory school closures.

Abstract

Importance  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.

Objective  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.

Exposures  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.

Results  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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Article Information

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 (fredzimmerman@ucla.edu).

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.

References
1.
Centers for Disease Control and Prevention. Operating schools during COVID-19: CDC’s considerations. The importance of reopening America’s schools this Fall. Updated December 30, 2020. Accessed July 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/reopening-schools.html
2.
National Academies of Sciences, Engineering, and Medicine.  Reopening K-12 Schools During the COVID-19 Pandemic: Prioritizing Health, Equity, and Communities. National Academies Press; 2020.
3.
American Academy of Pediatrics. COVID-19 guidance for safe schools. Updated January 5, 2021. Accessed September 1, 2020. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/
4.
Psacharopoulos  G , Patrinos  H , Collis  V , Vegas  E . The COVID-19 cost of school closures. Brookings Institution. Published April 29, 2020. Accessed September 15, 2020. https://www.brookings.edu/blog/education-plus-development/2020/04/29/the-covid-19-cost-of-school-closures/
5.
Epstein  JM , Hammond  RA . Cost and healthcare impacts of US school closures: an update. NYU School of Global Public Health. Published March 11, 2020. Accessed September 15, 2020. https://cdn.vox-cdn.com/uploads/chorus_asset/file/19931500/EpsteinSchoolClosures.pdf
6.
Fuchs-Schündeln  N , Krueger  D , Ludwig  A , Popova  I . The long-term distributional and welfare effects of COVID-19 school closures. National Bureau of Economic Research. Published September 2020. Accessed January 19, 2021. https://www.nber.org/system/files/working_papers/w27773/w27773.pdf
7.
Dorn  E , Hancock  B , Sarakatsannis  J , Viruleg  E .  COVID-19 and Student Learning in the United States: The Hurt Could Last a Lifetime. McKinsey and Co; 2020.
8.
Bin Nafisah  S , Alamery  AH , Al Nafesa  A , Aleid  B , Brazanji  NA .  School closure during novel influenza: a systematic review.   J Infect Public Health. 2018;11(5):657-661. doi:10.1016/j.jiph.2018.01.003 PubMedGoogle ScholarCrossref
9.
Viner  RM , Russell  SJ , Croker  H ,  et al.  School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review.   Lancet Child Adolesc Health. 2020;4(5):397-404. doi:10.1016/S2352-4642(20)30095-X PubMedGoogle ScholarCrossref
10.
Courtemanche  C , Garuccio  J , Le  A , Pinkston  J , Yelowitz  A .  Strong social distancing measures in the United States reduced the COVID-19 growth rate.   Health Aff (Millwood). 2020;39(7):1237-1246. doi:10.1377/hlthaff.2020.00608 PubMedGoogle ScholarCrossref
11.
Hsiang  S , Allen  D , Annan-Phan  S ,  et al.  The effect of large-scale anti-contagion policies on the COVID-19 pandemic.   Nature. 2020;584(7820):262-267. doi:10.1038/s41586-020-2404-8 PubMedGoogle ScholarCrossref
12.
Ismail  SA , Saliba  V , Bernal  JL , Ramsay  ME , Ladhani  S .  SARS-CoV-2 infection and transmission in educational settings: cross-sectional analysis of clusters and outbreaks in England.   Lancet Infect Dis. Published online December 8, 2020. doi:10.1016/S1473-3099(20)30882-3PubMedGoogle Scholar
13.
Auger  KA , Shah  SS , Richardson  T ,  et al.  Association between statewide school closure and COVID-19 incidence and mortality in the US.   JAMA. 2020;324(9):859-870. doi:10.1001/jama.2020.14348 PubMedGoogle ScholarCrossref
14.
The New York Times. Coronavirus (COVID-19) data in the United States. Published 2020 (updated continuously). Accessed September 10, 2020. https://github.com/nytimes/covid-19-data#readme
15.
Integrated Public Use Microdata Series. IPUMS National Historical Geographic Information System: version 14.0. Published 2019. Accessed January 19, 2021. https://www.nhgis.org/
16.
Community Mobility Reports Help. Overview. Published 2020. Accessed July 31, 2020. https://support.google.com/covid19-mobility/answer/9824897?hl=en&ref_topic=9822927.
17.
Ruktanonchai  NW , Ruktanonchai  CW , Floyd  JR , Tatem  AJ .  Using Google location history data to quantify fine-scale human mobility.   Int J Health Geogr. 2018;17(1):28. doi:10.1186/s12942-018-0150-z PubMedGoogle ScholarCrossref
18.
Rogers  S . What is Google Trends data—and what does it mean? Medium.com. Published July 1, 2016. Accessed July 31, 2020. https://medium.com/google-news-lab/what-is-google-trends-data-and-what-does-it-mean-b48f07342ee8
19.
Mavragani  A , Ochoa  G .  Google Trends in infodemiology and infoveillance: methodology framework.   JMIR Public Health Surveill. 2019;5(2):e13439. doi:10.2196/13439 PubMedGoogle Scholar
20.
Parker  J , Cuthbertson  C , Loveridge  S , Skidmore  M , Dyar  W .  Forecasting state-level premature deaths from alcohol, drugs, and suicides using Google Trends data.   J Affect Disord. 2017;213:9-15. doi:10.1016/j.jad.2016.10.038 PubMedGoogle ScholarCrossref
21.
OpenTable. The state of the restaurant industry. Updated July 28, 2020. Accessed July 28, 2020. https://www.opentable.com/state-of-industry
22.
Kaiser Family Foundation. Total number of residents in certified nursing facilities. State Health Facts website. Published January 5, 2017. Accessed August 8, 2020. https://www.kff.org/other/state-indicator/number-of-nursing-facility-residents/?currentTimeframe=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
23.
Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry, Geospatial Research, Analysis, and Services Program. Social Vulnerability Index 2018 data and documentation download. Reviewed September 15, 2020. Accessed August 8, 2020. https://svi.cdc.gov/data-and-tools-download.html
24.
The Atlantic. The COVID Tracking Project. Published 2020 (updated daily). Accessed August 8, 2020. https://covidtracking.com/data
25.
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS prevalence & trends data. Reviewed September 17, 2017. Accessed August 8, 2020. https://www.cdc.gov/brfss/brfssprevalence/index.html
26.
Elwert  F , Winship  C .  Endogenous selection bias: the problem of conditioning on a collider variable.   Annu Rev Sociol. 2014;40(1):31-53. doi:10.1146/annurev-soc-071913-043455 PubMedGoogle ScholarCrossref
27.
Thornton  DL .  A note on the efficiency of the Cochrane-Orcutt estimator of the ar(1) regression model.   J Econometrics. 1987;36(3):369-376. doi:10.1016/0304-4076(87)90008-X Google ScholarCrossref
28.
Glaeser  EL , Jin  GZ , Leyden  BT , Luca  M . Learning from Deregulation: The Asymmetric Impact of Lockdown and Reopening on Risky Behavior During COVID-19. National Bureau of Economic Research; 2020.
29.
Levinson  M , Cevik  M , Lipsitch  M .  Reopening primary schools during the pandemic.   N Engl J Med. 2020;383(10):981-985. doi:10.1056/NEJMms2024920 PubMedGoogle ScholarCrossref
30.
Carroll  AE . When it comes to COVID-19, most of us have risk exactly backward. New York Times. Published August 28, 2020. Accessed September 17, 2020. https://www.nytimes.com/2020/08/28/opinion/coronavirus-schools-tradeoffs.html
31.
Landeros  A , Ji  X , Lange  KL ,  et al.  An examination of school reopening strategies during the SARS-CoV-2 pandemic.   medRxiv. Preprint posted online August 6, 2020.Google Scholar
32.
Silverman  M , Sibbald  R , Stranges  S .  Ethics of COVID-19–related school closures.   Can J Public Health. 2020;111(4):462-465. doi:10.17269/s41997-020-00396-1 PubMedGoogle ScholarCrossref
33.
Bayham  J , Fenichel  EP .  Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study.   Lancet Public Health. 2020;5(5):e271-e278. doi:10.1016/S2468-2667(20)30082-7 PubMedGoogle ScholarCrossref
34.
Lempel  H , Epstein  JM , Hammond  RA .  Economic cost and health care workforce effects of school closures in the US.   PLoS Curr. 2009;1:RRN1051. doi:10.1371/currents.RRN1051 PubMedGoogle Scholar
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