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

This population epidemiology study estimates associations of school closures in the US and the timing of those closures in March 2020 with change in daily coronavirus disease 2019 (COVID-19) incidence and mortality through the first week of May, accounting for other contemporaneous public health interventions. 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 100000 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 100000 residents. Results COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100000 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 100000 population over 26 days and with 1.5 fewer deaths per 100000 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. 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 100000 population over 26 days and with 1.5 fewer deaths per 100000 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.