Measures in School Settings

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

Why are measures implemented in the school important to contain COVID-19?

To help prevent the spread of SARS-CoV-2 and COVID-19, various national and subnational governments initiated different measures within the society and school settings. Some of the largest controversies existed among decisions made about the school settings, affecting more than 90% of the global student population. The aim of school closures was to reduce the spread of the virus and limit community transmission by preventing contacts between school staff and students. Implementing different measures in the school settings was a way to evaluate which measures would safely permit reopening of schools during the COVID-19 pandemic.

Do measures implemented in the school work to contain COVID-19?

  • Certainty of evidence for each intervention was very low or low according to GRADE scale; lack of confidence in findings
  • Measures in school settings may decrease the number of COVID-19 cases and deaths but can result in unintentional outcomes such as negative impacts on mental/physical health & overall wellbeing
  • Difficult to estimate the specific effects of interventions as most studies evaluated a mixture of interventions
  • Most were modelling studies thus there are concerns about study quality
  • Lack of real-world and empirical evidence; very limited data available on interventions that were actually implemented

 Equity: Do measures implemented in the school work for the disadvantaged?   

  • Most of the studies were conducted in high-income countries; concerns exist around generalizability and transferability of data to low and middle-income countries
  • Low and middle-income countries have shown to be impacted by school closures with more detrimental effects than high-income countries-increasing inequalities, parents missing out on income, children not receiving vaccinations and increased school dropout rates 
  • Populations with lower socioeconomic status were not examined-differences may exist in how interventions are carried out 

Intervention Delivery

  • A rapid review was conducted, included 38 studies; consisting of modelling studies, three observational studies, one quasi‐experimental and one experimental study with modelling components (randomized controlled trials)
  • Modelling studies consist of assumptions, with some closer to real-life conditions than other 
  • Studies assessed the effects of implemented measures within school settings to either safely reopen schools, keep schools open or both

Measures were categories into four broad groups:

 1) Measures reducing the opportunity for contacts (most commonly assessed)
  • Interventions impacting organization and timing of different school activities
  • For example, alternating attendance, reduced cohort sizes, phased school reopening, staggered start and end times, and permitting school attendance for certain grades

2) Measures making contacts safer
  • Interventions that impact behaviors of school staff and students
  • For example, handwashing guidelines, cleaning intervention, and using face masks
  • Also addressed measures to modify the physical environment
  • For example, changes to school activities, ventilation interventions, and combined measures to make contacts safer

3) Surveillance and response measures
  • Strategies to screen or test individuals and groups for the virus, followed by appropriate actions 
  • Screening and quarantine based on symptoms

4) Multicomponent measures
  • Included combinations of at least two of the previously mentioned categories: face masks, testing, quarantine, cleaning, reducing cohort sizes, and modification of school activities

All measures looked for the following outcomes:

  1. Transmission-related
  2. Healthcare utilization
  3. Societal, economic and ecological
  4. Other healthcare outcomes
  • For comparison, the following took place: schools with no implemented measures, less extensive measures, closed schools, or single vs. multiple implemented measures

Population and Setting 

  • Included following populations at risk of SARS-CoV-2 and COVID-19:
    • Students-aged 4-18
    • School staff
    • Teachers
    • Community members-general population or parents/caretakers
  • 20 studies were completed in North or South America, 2 in China, and 16 in Europe
  • Limited research conducted in Asia, South America and Australia, with no research from Africa. 
  • Setting: schools-included boarding schools, day schools, school grounds, any activity organized or related to the school, and vehicles arriving or returning around school grounds
  • Majority of the studies did not distinguish between the school types, primary or secondary. If there was no differentiation, the focus was on primary school settings
  • Non-human transmission studies were excluded

* See links for summary of findings tables

Table 1: Summary of Findings Table 1.docx

Table 2: Summary of Findings Table 2.docx

Table 3: Summary of Findings Table 3.docx

Table 4: Summary of Findings Table 4.docx

Relevance of the review for disadvantaged communities
Findings
Interpretation
Equity - Which of the PROGRESS groups examined

 

All of the participants were aged 4-18 in the school setting. There was no mention about differentiation between gender, sex, ethnicity. 

 

The socioeconomic status/inequalities of the different countries was to be considered but subgroup analysis did not occur because most studies failed to report on this area. Studies also failed to report on cultural aspects. 

 

Little is known about the educational impacts of implementing various interventions/measures to prevent viral transmission.

 

The results of this rapid review are applicable to students in the school setting aged 4-18, teachers, school staff and some community members (parents/caretakers/general population). All of the interventions have low to very low certainty of evidence. 

 

The various socioeconomic status of different regions and countries may impact the way interventions are utilized and implemented. Many studies failed to report on socioeconomic status and cultural aspects, thus impacting transferability, feasibility and usefulness of the measures. 

 

School closures can have a negative impact on education success and outcomes. Educational outcomes are to be assessed in future research-the impact of intervention implementation to decrease virus transmission should not be at the expense of educational outcomes for students.  
Equity Applicability

 

Most of the studies were based in high-income countries, particularly in Europe and North America. The relevance of school interventions for preventing transmission of COVID-19 was not considered for low and middle-income countries.

 

The results of the review are likely transferable to other high-income countries but do have very low level certainty of evidence. It is important to keep in mind the regional differences such as socioeconomic status that exist within countries and the impacts this may have on transferability of data. 

The results may not apply to low and middle income countries. Low-income countries have different resources such as classroom space and amount of teaching staff. Future research should study the effects of non-pharmaceutical interventions for safe school re-opening within these countries.

Cost-equity

This rapid review commented on the cost-effectiveness of implementing interventions.

 

Three studies examined the cost of testing different interventions, showing mixed results. One study showed that testing school staff and students in primary and secondary schools for 1.5 months versus no intervention would cost $816 million Canadian dollars.

Financial resources would also be required to provide tools for virtual learning, changes to infrastructure to accommodate physical distancing between students in classrooms, and availability of space for intervention implementation.

Cost-effectiveness of intervention implementation in low & middle income countries must also be considered-there may be limited financial availability for execution of interventions.

The closure of schools may cause a decrease in gross domestic product because of parental requirements to care for children, thus limiting economic productivity.
Monitoring & Evaluation for PROGRESS groups

 

Long-term evaluation for effectiveness of controlling viral transmission by vaccination in younger age groups is required.

Other studies should examine the feasibility of implementing these interventions in low and middle-income countries.

Monitoring educational impacts and outcomes.


During the time of this rapid review, vaccinations were yet approved or administered for younger children in the school setting; thus future research should examine vaccination impacts on controlling viral transmission in the school setting among younger age groups.

Further research is required to evaluate intervention implementation in low and middle-income countries. Including studies in other languages may also increase data collection results & inclusion of relevant studies.

Evaluation of the educational impacts of these measures is needed- evaluating if there were any detrimental impacts of school closures for childrens' learning.

This summary is based on the following systematic review:    

Krishnaratne S, Littlecott H, Sell K, Burns J, Rabe JE, Stratil JM, Litwin T, Kreutz C, Coenen M, Geffert K, Boger AH, Movsisyan A, Kratzer S, Klinger C, Wabnitz K, Strahwald B, Verboom B, Rehfuess E, Biallas RL, Jung-Sievers C, Voss S, Pfadenhauer LM. Measures implemented in the school setting to contain the COVID-19 pandemic. Cochrane Database of Systematic Reviews 2022, Issue 1. Art. No.: CD015029. DOI: 10.1002/14651858.CD015029.

Link to PDF: Measures implemented in the school setting .pdf

Comments on this summary? Please contact Jennifer Petkovic.                                                                                                                                                            This summary was prepared by Jessica Tiilikainen.