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Meta-Analysis
. 2024 May 2;5(5):CD015029.
doi: 10.1002/14651858.CD015029.pub2.

Measures implemented in the school setting to contain the COVID-19 pandemic

Hannah Littlecott  1   2 , Shari Krishnaratne  1   2   3 , Jacob Burns  1   2 , Eva Rehfuess  1   2 , Kerstin Sell  1   2 , Carmen Klinger  1   2 , Brigitte Strahwald  1   2 , Ani Movsisyan  1   2 , Maria-Inti Metzendorf  4 , Petra Schoenweger  1   2 , Stephan Voss  1   2 , Michaela Coenen  1   2 , Roxana Müller-Eberstein  1   2 , Lisa M Pfadenhauer  1   2
Affiliations
Meta-Analysis

Measures implemented in the school setting to contain the COVID-19 pandemic

Hannah Littlecott et al. Cochrane Database Syst Rev. .

Abstract

Background: More than 767 million coronavirus 2019 (COVID-19) cases and 6.9 million deaths with COVID-19 have been recorded as of August 2023. Several public health and social measures were implemented in schools to contain the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and prevent onward transmission. We built upon methods from a previous Cochrane review to capture current empirical evidence relating to the effectiveness of school measures to limit SARS-CoV-2 transmission.

Objectives: To provide an updated assessment of the evidence on the effectiveness of measures implemented in the school setting to keep schools open safely during the COVID-19 pandemic.

Search methods: We searched the Cochrane COVID-19 Study Register, Educational Resources Information Center, World Health Organization (WHO) COVID-19 Global literature on coronavirus disease database, and the US Department of Veterans Affairs Evidence Synthesis Program COVID-19 Evidence Reviews on 18 February 2022.

Selection criteria: Eligible studies focused on measures implemented in the school setting to contain the COVID-19 pandemic, among students (aged 4 to 18 years) or individuals relating to the school, or both. We categorized studies that reported quantitative measures of intervention effectiveness, and studies that assessed the performance of surveillance measures as either 'main' or 'supporting' studies based on design and approach to handling key confounders. We were interested in transmission-related outcomes and intended or unintended consequences.

Data collection and analysis: Two review authors screened titles, abstracts and full texts. We extracted minimal data for supporting studies. For main studies, one review author extracted comprehensive data and assessed risk of bias, which a second author checked. We narratively synthesized findings for each intervention-comparator-outcome category (body of evidence). Two review authors assessed certainty of evidence.

Main results: The 15 main studies consisted of measures to reduce contacts (4 studies), make contacts safer (7 studies), surveillance and response measures (6 studies; 1 assessed transmission outcomes, 5 assessed performance of surveillance measures), and multicomponent measures (1 study). These main studies assessed outcomes in the school population (12), general population (2), and adults living with a school-attending child (1). Settings included K-12 (kindergarten to grade 12; 9 studies), secondary (3 studies), and K-8 (kindergarten to grade 8; 1 study) schools. Two studies did not clearly report settings. Studies measured transmission-related outcomes (10), performance of surveillance measures (5), and intended and unintended consequences (4). The 15 main studies were based in the WHO Regions of the Americas (12), and the WHO European Region (3). Comparators were more versus less intense measures, single versus multicomponent measures, and measures versus no measures. We organized results into relevant bodies of evidence, or groups of studies relating to the same 'intervention-comparator-outcome' categories. Across all bodies of evidence, certainty of evidence ratings limit our confidence in findings. Where we describe an effect as 'beneficial', the direction of the point estimate of the effect favours the intervention; a 'harmful' effect does not favour the intervention and 'null' shows no effect either way. Measures to reduce contact (4 studies) We grouped studies into 21 bodies of evidence: moderate- (10 bodies), low- (3 bodies), or very low-certainty evidence (8 bodies). The evidence was very low to moderate certainty for beneficial effects of remote versus in-person or hybrid teaching on transmission in the general population. For students and staff, mostly harmful effects were observed when more students participated in remote teaching. Moderate-certainty evidence showed that in the general population there was probably no effect on deaths and a beneficial effect on hospitalizations for remote versus in-person teaching, but no effect for remote versus hybrid teaching. The effects of hybrid teaching, a combination of in-person and remote teaching, were mixed. Very low-certainty evidence showed that there may have been a harmful effect on risk of infection among adults living with a school student for closing playgrounds and cafeterias, a null effect for keeping the same teacher, and a beneficial effect for cancelling extracurricular activities, keeping the same students together and restricting entry for parents and caregivers. Measures to make contact safer (7 studies) We grouped studies into eight bodies of evidence: moderate- (5 bodies), and low-certainty evidence (3 bodies). Low-certainty evidence showed that there may have been a beneficial effect of mask mandates on transmission-related outcomes. Moderate-certainty evidence showed full mandates were probably more beneficial than partial or no mandates. Evidence of a beneficial effect of physical distancing on risk of infection among staff and students was mixed. Moderate-certainty evidence showed that ventilation measures probably reduce cases among staff and students. One study (very low-certainty evidence) found that there may be a beneficial effect of not sharing supplies and increasing desk space on risk of infection for adults living with a school student, but showed there may be a harmful effect of desk shields. Surveillance and response measures (6 studies) We grouped studies into seven bodies of evidence: moderate- (3 bodies), low- (1 body), and very low-certainty evidence (3 bodies). Daily testing strategies to replace or reduce quarantine probably helped to reduce missed school days and decrease the proportion of asymptomatic school contacts testing positive (moderate-certainty evidence). For studies that assessed the performance of surveillance measures, the proportion of cases detected by rapid antigen detection testing ranged from 28.6% to 95.8%, positive predictive value ranged from 24.0% to 100.0% (very low-certainty evidence). There was probably no onward transmission from contacts of a positive case (moderate-certainty evidence) and replacing or shortening quarantine with testing may have reduced missed school days (low-certainty evidence). Multicomponent measures (1 study) Combining multiple measures may have led to a reduction in risk of infection among adults living with a student (very low-certainty evidence).

Authors' conclusions: A range of measures can have a beneficial effect on transmission-related outcomes, healthcare utilization and school attendance. We rated the current findings at a higher level of certainty than the original review. Further high-quality research into school measures to control SARS-CoV-2 in a wider variety of contexts is needed to develop a more evidence-based understanding of how to keep schools open safely during COVID-19 or a similar public health emergency.

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Conflict of interest statement

JB: German Federal Ministry of Education and Research (Grant/Contract). Also see below

MC: Bundesministerium für Bildung und Forschung (Grant/Contract). Also see below

CK: no relevant interests. Also see below

SK: German Federal Ministry of Education and Research (Grant/Contract)

HL: no relevant interests. Also see below

M‐IM: no relevant interests; performs editorial activities for reviews overseen by the Cochrane Metabolic and Endocrine Disorders Group

AM: no relevant interests. Also see below

RME: none known

LP: German Federal Ministry of Education and Research (Grant/Contract). Also see below

ER: no relevant interests. Also see below

PS: no relevant interests. Also see below

KS: no relevant interests. Also see below

BS: German Federal Ministry of Education and Research (Grant/Contract). Also see below

SV: no relevant interests. Also see below.

Other details:

ER declares being a member of the scientific advisory board of the Robert Koch Institute that has issued guidance on schooling during COVID‐19, but states that she has not been involved with developing this guidance; she also declares being a member of the World Health Organization (WHO) Regional Office for Europe’s Technical Advisory Group on Schooling during COVID‐19 and, in this role, has been involved with advising the WHO Regional Office for Europe on the issue.

LP, ER, and BS declare being part of the scientific secretariat that supports the development of a living interdisciplinary, evidence‐based and consensus‐based guideline on measures to prevent and control SARS‐CoV‐2 transmission in schools, registered with the Association of the Scientific Medical Societies (AWMF) in Germany (https://register.awmf.org/de/leitlinien/detail/027-076).

MC and ER are involved in the conduct of an ongoing study that, after completion, may potentially be eligible for inclusion in the review (the study COVID Kids Bavaria was financed by the Bavarian Ministry of Research and Art).

LP, JB, and KS are involved in an ongoing study focusing on the implementation of school‐related measures to contain the COVID‐19 pandemic in the German state of Bavaria (INSIDE: ImplementieruNg Schulmaßnahmen covID‐19 bayErn). As part of this project, an effectiveness‐focused substudy is planned to be undertaken in the near future.

The study COVID Kids Bavaria was funded by the Bavarian Ministry of Research and Art. The study INSIDE: ImplementieruNg Schulmaßnahmen covID‐19 bayErn) was funded by the Bavarian Ministry of Science and the Arts (“Corona Forschungsprogramm 2021/22” – Corona research program 2021/22).

Figures

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A posteriori logic model (based on observations of the evidence)
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Study categorization process
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PRISMA flow diagram
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Evidence map
See this image and copyright information in PMC

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References

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