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Iyengar A, Hanon S, Bruns R, Olsiewski P, Gronvall GK. COVID-19 Mitigation in a K-12 School Setting: A Case Study of Avenues: The World School in New York City. Health Secur 2024; 22:210-222. [PMID: 38624262 DOI: 10.1089/hs.2023.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
In this case study, we describe a well-resourced private school in New York City that implemented COVID-19 mitigation measures based on public health expert guidance and the lessons learned from this process. Avenues opened in New York City in 2012 and has since expanded, becoming Avenues: The World School, with campuses in São Paulo, Brazil; Shenzhen, China; the Silicon Valley, California; and online. It offers education at 16 grade levels: 2 early learning years, followed by a prekindergarten through grade 12. We describe the mitigation measures that Avenues implemented on its New York campus. We compare COVID-19 case prevalence at the school with COVID-19 case positivity in New York City, as reported by the New York State Department of Health. We also compare the school's indoor air quality to ambient indoor air quality measures reported in the literature. The school's mitigation measures successfully reduced the prevalence of COVID-19 among its students, staff, and faculty. The school also established a consistently high level of indoor air quality safety through various ventilation mechanisms, designed to reduce common indoor air pollutants. The school received positive parent and community feedback on the policies and procedures it established, with many parents commenting on the high level of trust and quality of communication established by the school. The successful reopening provides useful data for school closure and reopening standards to prepare for future pandemic and epidemic events.
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Affiliation(s)
- Ananya Iyengar
- Ananya Iyengar, MSPH, was a Graduate Research Assistant, at the Johns Hopkins Center for Health Security, Baltimore, MD
| | - Steve Hanon
- Steve Hanon, MBA, is Chief Campus Operations Officer, Avenues: The World School, New York, NY
| | - Richard Bruns
- Richard Bruns, PhD, is a Senior Scholar, at the Johns Hopkins Center for Health Security, Baltimore, MD, Richard Bruns is also an Assistant Scientist, the Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Paula Olsiewski
- Paula Olsiewski, PhD, is a Contributing Scholar, at the Johns Hopkins Center for Health Security, Baltimore, MD
| | - Gigi Kwik Gronvall
- Gigi Kwik Gronvall, PhD, is a Senior Scholar, at the Johns Hopkins Center for Health Security, Baltimore, MD, Gigi Kwik Gronvall is also an Associate Professor, in the Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Littlecott H, Krishnaratne S, Burns J, Rehfuess E, Sell K, Klinger C, Strahwald B, Movsisyan A, Metzendorf MI, Schoenweger P, Voss S, Coenen M, Müller-Eberstein R, Pfadenhauer LM. Measures implemented in the school setting to contain the COVID-19 pandemic. Cochrane Database Syst Rev 2024; 5:CD015029. [PMID: 38695826 PMCID: PMC11064884 DOI: 10.1002/14651858.cd015029.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
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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Affiliation(s)
- Hannah Littlecott
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Shari Krishnaratne
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob Burns
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Eva Rehfuess
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Kerstin Sell
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Carmen Klinger
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Brigitte Strahwald
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Ani Movsisyan
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University, Düsseldorf, Germany
| | - Petra Schoenweger
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Stephan Voss
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Michaela Coenen
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Roxana Müller-Eberstein
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Lisa M Pfadenhauer
- Institute for Medical Information Processing, Biometry and Epidemiology - IBE, Chair of Public Health and Health Services Research, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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Gorgels KMF, van Alphen LB, van der Veer BMJW, Hackert VH, Hensels AYJ, Heijer CDJD, Dingemans J, Savelkoul PHM, Hoebe CJPA. Increased transmissibility of SARS-CoV-2 alpha variant (B.1.1.7) in children: three large primary school outbreaks revealed by whole genome sequencing in the Netherlands. BMC Infect Dis 2022; 22:713. [PMID: 36038845 PMCID: PMC9421630 DOI: 10.1186/s12879-022-07623-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Variant of concern (VOC) SARS-CoV-2 alpha variant (B.1.1.7) was the dominant strain in the Netherlands between March 2021–June 2021. We describe three primary school outbreaks due to the alpha variant using whole genome sequencing with evidence of large-scale transmission among children, teachers and their household contacts. Method All outbreaks described were investigated by the South Limburg Public Health Service, the Netherlands. A case was defined as an individual with a real-time polymerase chain reaction test or antigen test positive for SARS-CoV-2. Whole genome sequencing was performed on random samples from at least one child and one teacher of each affected class. Results Peak attack rates in classes were 53%, 33% and 39%, respectively. Specific genotypes were identified for each school across a majority of affected classes. Attack rates were high among staff members, likely to promote staff-to-children transmission. Cases in some classes were limited to children, indicating child-to-child transmission. At 39%, the secondary attack rate (SAR) in household contacts of infected children was remarkably high, similar to SAR in household contacts of staff members (42%). SAR of household contacts of asymptomatic children was only 9%. Conclusion Our findings suggest increased transmissibility of the alpha variant in children compared to preceding non-VOC variants, consistent with a substantial rise in the incidence of cases observed in primary schools and children aged 5–12 since the alpha variant became dominant in March 2021. Lack of mandatory masking, insufficient ventilation and lack of physical distancing also probably contributed to the school outbreaks. The rise of the delta variant (B.1.617.2) since July 2021 which is estimated to be 55% more transmissible than the alpha variant, provides additional urgency to adequate infection prevention in school settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07623-9.
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Affiliation(s)
- Koen M F Gorgels
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.
| | - Lieke B van Alphen
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Brian M J W van der Veer
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Volker H Hackert
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Audrey Y J Hensels
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands
| | - Casper D J den Heijer
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Jozef Dingemans
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Christian J P A Hoebe
- Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, PO Box 33, 6400 AA, Heerlen, The Netherlands.,Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.,Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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