Closing schools limits educational attainment and has other consequences for health

The World Bank estimated that school closures affected 1.6 billion children at the end of 2021, plunging up to 70% of the world’s children into learning poverty, defined as being unable to read and understand a simple text by age 10 years.6 In the UK, school closures have resulted in an estimated £350 billion in lifetime earnings loss for the current generation of children.7 The World Bank estimate worldwide learning losses with a present value of US$17 trillion.6

Educational attainment was heavily impacted, especially among those already disadvantaged such as those with special educational needs and those from lower socioeconomic backgrounds.8 9 In Uganda, the proportion of primary 3 pupils unable to recognise letters of the alphabet has doubled.10 In South Africa, grade 4 students lost between 62% and 81% of a year of learning when measured in terms of reading outcomes.11 A differences-in-differences estimate contrasting to the year prior to the pandemic estimates school drop-out rates in Brazil are estimated to be as high as 35%.12 Even in countries with remote learning, large attainment gaps were observed between in-person and remote schooling. For example, in the USA, passing rates in maths declined by 14.2% on average and this decline was 10.1% smaller for districts that adopted fully in-person schooling.13 In the Netherlands, the ‘gold standard for remote education, a significant attainment gap equivalent to one-fifth of a school year accrued.14 These findings suggest the negative impact of school closures on attainment is evident in low-income and middle-income countries, and in high-income settings.

In contrast, in Sweden where in-person schooling was prioritised, no drop in educational attainment or widening of inequalities occurred during the pandemic.15 The clinical impact of COVID-19 on children in Sweden and Iceland (where schools also remained open) was in line with other experiences globally.16 In Iceland, of all 1749 children with SARS-CoV-2 infection from February 2020 to August 2021, none had severe symptoms and 374 (21.5%) were asymptomatic. The source of infection was a household member in 65% of cases and in the country only one probable multisystem inflammatory syndrome in children (MIS-C) case was reported.16 The impact of COVID-1917 was in line with other reports from other countries.18

Physical and mental health and well-being of children and young people were also impacted by school closures. A recent systematic review including 21 studies from 11 countries covering >96 000 subjects from 3 to 24 years of age found longitudinal deterioration of mental health, with increased depression, anxiety and psychological distress compared with prepandemic.19 A systematic review of systematic reviews found eight looking at the impact on school closures on mental health of children, all of which reported an associated decline and most notably with symptoms of anxiety.9 Once more, it also appeared that more vulnerable children were at higher risk, including females, children from lower socioeconomic backgrounds and children with neurodiversity.

School closures also have other long-term consequences for children. As a result of the pandemic, UNICEF reports increased rates of childhood marriage with up to 10 million more girls being at risk of becoming child brides by 2030.20 UNICEF highlights that school closures lead to girls spending more time at home and unsupervised, increasing their exposure to sexual activity, sexual violence and unwanted pregnancy,20 exacerbate school drop outs due to financial pressure on households and parents during the pandemic21 and increase negative effects on nutritional safety among 370 million children not receiving a school meal in 150 countries.22

Schools do not inevitably increase COVID-19 transmission

School closures have limited benefits on COVID-19 transmission. A systematic review including 40 studies with lowest risk of bias from 140 countries found little to no impact of school closures on COVID-19 burden.23 A systematic review of systematic reviews on school closures found six suggesting a reduction of transmission and four which were either uncertain or found no reduction in transmission. The quality of all included studies were low or critically low.9 In addition, it is difficult to measure the impact of school closures as many studies performed early in the pandemic examine a period when several measures were implemented simultaneously making it almost impossible to identify the impact of single measures17 24 and studies during the second waves happened in the setting of increased mitigations and staggered implementation of other NPIs.25

There may be circumstances when proportionate and effective mitigating measures could be beneficial in school settings following evidence-based interventions that are effective, safe and feasible. For example, identifying least well-ventilated schools and improving building ventilation systems may carry benefits beyond COVID-19 and so be a wise investment for population health in the long term.26 The use of rapid tests may be a less invasive alternative to quarantining.27 Face masks have been widely used during the pandemic, especially for older children, although evidence around their effectiveness in community settings such as schools remains uncertain.9 28

The overall risk of harm from severe COVID-19 disease is low

Throughout the pandemic, data suggest significantly lower risk of severe outcomes of COVID-19 among children than adults, although the impact of rare severe cases remains relevant.29 The rate of MIS-C was initially thought to be around 1 in 3000–4000 cases,30 and current evidence suggests children aged 7 years has the lowest infection fatality rate (0.0023%).31 While a small number of children suffer prolonged symptoms from postacute COVID-19 syndromes (PACS—also known as ‘long COVID’) bearing a huge negative impact on quality of life for the child and family, studies comparing adults and children from the same household found that children appear to be at significantly lower risk of PACS.32 Observational prospective studies with control groups have suggested the incidence of PACS may range from <1% to 2%.33 Data from the UK indicate that re-infections do not lead to more serious outcomes,34 and recent studies demonstrate the risk of MIS-C is decreasing, probably due to viral mutations and immunity postinfection and/or vaccination.35 Vaccines which are safe and effective against severe disease in children with comorbidities are also now available, and increasingly accessible for countries in low-resource settings.

Another key rationale for closing schools was to reduce transmission from school-aged children to vulnerable adults in their households and communities. There are extensive data on this topic. A population-based cohort study examining risk of SARS-CoV-2 infection among 9 334 392 UK adults aged <65 years found that even in the prevaccine era adults living with children during wave 1 and 2 did not have an increased risk of COVID-19 or non-COVID-19 mortality.36 In Scotland, school teachers had a lower risk of severe COVID-19 than the general population (HR 0.56),37 and in Sweden the age-adjusted risk of intensive care admission for school teachers was not statistically different to the pooled risk of other occupations (excluding healthcare workers).38 A study in England and Wales between March and December 2020 found the absolute mortality rates for deaths with COVID-19 were low among those working in schools (from 10 per 100 000 in female primary school teachers to 39 per 100 000 male secondary school teachers) relative to many other occupations (range 9–50 per 100 000 in women; 10–143 per 100 000 in men), although there was weak evidence that secondary school teachers had slightly higher risks.39 These data highlight low risk of exposure to families and school staff from in-person school, even prior to the availability of vaccines.

Going forward

Independent inquiries about how governments have responded to the pandemic and which lessons can be learnt for future ones are necessary. It is vital that the health and well-being of children and other vulnerable populations are put at the centre of these inquiries, with a specific focus on how and why decisions regarding the closure of schools were made. Norway has been an exemplar in this regard,40 and after pressure from advocacy groups the UK inquiry will also focus on school closures.41

Should schools need to close, closures should be time limited, with clear criteria for reopening. There are many resources and tools to help guide the school reopening process, which include the involvement of children, parents and communities.42 It is important that lack of resources, unrealistic standards or the ability to institute guidelines and possible mitigation measures does not constitute an excuse for prolonging school closures.

Schools should be prioritised for additional financial and human-resource support, which may include extra funding for fragile families; access to volunteers; social and psychological support for children and their families, investment in air quality and ventilation; support for hybrid learning (eg, computers, internet connection) for extremely high-risk families who may temporarily be unable to attend schools.

Countries should produce guidance specifically dedicated to maintaining the operation of in-person schooling to be ready for use to ensure their safe operation and to minimise closures. Importantly, guidance must be feasible and proportional, with specific focus on resources for children with special educational needs or disabilities, and those from disadvantaged populations, who are both at higher risk of infection and the harms of absenteeism. Guidance should include input of all relevant stakeholders, including children and young people, parents, educators and public health professionals.

The priority is that children should attend school, in person, and guidelines for safe opening should be used to aid, not obstruct, the facilitation of this.