Abstract
School closures because of COVID-19 have left 1.6 billion students around the world without in-person classes for a prolonged period. To our knowledge, no study has documented whether reopening schools in low- and middle-income countries during the pandemic was associated with increased aggregate COVID-19 incidence and mortality with appropriate counterfactuals. To test whether reopening schools under appropriate protocols during the COVID-19 pandemic was associated with increased municipal-level COVID-19 cases and deaths in São Paulo State, Brazil. This observational study of municipalities in São Paulo State, Brazil, uses a difference-in-differences analysis to examine the association between municipal decisions to reopen schools during the COVID-19 pandemic and municipal-level COVID-19 case and death rates between October and December 2020. The study compared 129 municipalities that reopened schools in 2020 with 514 that did not and excluded data for 2 municipalities that reopened schools and closed then again. New COVID-19 cases and deaths per 10 000 inhabitants up to 12 weeks after school reopenings and municipal-level aggregate mobility for a subset of municipalities. There were 8764 schools in the 129 municipalities that reopened schools compared with 9997 in the control group of 514 municipalities that did not reopen schools. The municipalities that reopened schools had a cumulative COVID-19 incidence of 20 cases per 1000 inhabitants and mortality of 0.5 deaths per 1000 inhabitants in September 2020 (the baseline period) compared with an incidence of 18 cases per 1000 inhabitants and mortality of 0.45 deaths per 1000 inhabitants during the baseline period in the comparison group. The findings indicated that there were no statistically significant differences between municipalities that authorized schools to reopen and those that did not for (1) weekly new cases (difference-in-differences, -0.03; 95% CI, -0.09 to 0.03) and (2) weekly new deaths (difference-in-differences, -0.003; 95% CI, -0.011 to 0.004) before and after October 2020. Reopening schools was not associated with higher disease activity, even in relatively vulnerable municipalities, nor aggregate mobility. The findings from this study suggest that keeping schools open during the COVID-19 pandemic did not contribute to the aggregate disease activity.
Highlights
Most countries around the world closed schools to reduce COVID-19 infections for a prolonged period.[1,2] Beyond learning outcomes, school closures have been shown to have an adverse association with children’s well-being[1,2,3,4] and to increase dropouts.[5,6]In-person classes might contribute to COVID-19 incidence and mortality
Reopening schools was not associated with higher disease activity, even in relatively vulnerable municipalities, nor aggregate mobility
The findings from this study suggest that keeping schools open during the COVID-19 pandemic did not contribute to the aggregate disease activity
Summary
Most countries around the world closed schools to reduce COVID-19 infections for a prolonged period.[1,2] Beyond learning outcomes, school closures have been shown to have an adverse association with children’s well-being[1,2,3,4] and to increase dropouts.[5,6]In-person classes might contribute to COVID-19 incidence and mortality. Recent evidence suggests that the likelihood of infection among family members and school staff increases substantially when schools are open.[7,8] Second, nonpharmaceutical measures have been shown to contribute to slowing down disease activity.[9,10,11,12,13,14,15] School closures were typically included in these interventions, as they are more densely populated than most other establishments.[16,17,18,19] Third, the mobility of primary caregivers is expected to increase when children are at school, potentially increasing transmission and beyond the school setting.[20,21] The risks of in-person classes might be especially high in low- and middle-income countries where schools may lack resources for robust mitigation strategies that reduce transmission.[22,23,24]
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