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

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.

Figure 1.. Observed Daily COVID-19 Incidence and Mortality by Cumulative Incidence Quartile at the Time of School Closure

COVID-19 indicates coronavirus disease 2019.

Figure 2.. Modeled Association of School Closure With Coronavirus Disease 2019 (COVID-19) Incidence and Mortality

The data markers indicate the national unadjusted daily rates. The lines depict aggregated national daily rates adjusted for each state’s unique set of testing and demographic characteristics on each day of the study period with 95% CIs depicted by gray lines. Six weeks after school closure, states in the lowest quartile had fewer new cases and fewer deaths compared with the states in the highest quartile. Panels A and B were adjusted for all model components retained in the incidence model (intercept: percentage of state’s population aged ≤15 years, percentage of state’s population aged ≥65 years, and US Centers for Disease Control and Prevention [CDC] social vulnerability index; before school closure: stay-at-home or shelter-in-place order, restaurant and bar closure, testing rate per 1000 residents, and urban density; after school closure: testing rate per 1000 residents, stay-at-home or shelter-in-place order, percentage of state’s population aged ≥65 years, number of nursing home residents per 1000 people, and urban density). Panels C and D were adjusted for all model components retained in the mortality model (intercept: percentage of state’s population aged ≤15 years, percentage of state’s population aged ≥65 years, and CDC social vulnerability index; before school closure: stay-at-home or shelter-in-place order, prohibition of gatherings with >10 people, restaurant and bar closure, percentage of state’s population aged ≤15 years, percentage of state’s population aged ≥65 years, number of nursing home residents per 1000 people, and urban density; after school closure: restaurant and bar closure, number of nursing home residents per 1000 people, and urban density).