Tough Call: Closing Public Schools During Infectious Disease Outbreaks
If you lived in Maryland this past winter and had school-aged children, you may have had one or two mornings where you thought to yourself: who decides to close schools for inclement weather? (You may have also wondered: what were they thinking?). As tough a job as it might be to make the decision to close for inclement weather, it’s even tougher when the circumstances are for public health reasons—such as an infectious disease outbreak.
South Korea is learning this lesson as it responds to Middle Eastern Respiratory Syndrome, or MERS. As part of its response to ensure the respiratory disease stays contained, it closed over 2200 schools and universities. Then, just as school boards recommended shutting even more schools, a World Health Organization (WHO) team studying the outbreak urged South Korea to re-open the schools. The team, a joint mission between South Korea and WHO, stated that “schools have not been linked to the transmission of [the virus].” Indeed, in spite of 13 new cases and two new deaths (as of June 10th), all new cases have been traced back to hospitals as the points of exposure/transmission. Nonetheless, places of common gathering, such as department stores, theatres, and amusement parks, have seen a steep decrease in sales, as people avoid those areas for fear of exposure. Schools, which can house hundreds of students, seem like they would be a hotbed of transmission for infectious diseases—and indeed, often, they are.
The seasonal flu of 2014 hit the U.S. hard everywhere, but perhaps hardest in the South. There, several states, including Georgia, North Carolina, and Tennessee, saw absentee rates in schools as high as 30%. Facing high absenteeism from students as well as teachers, many of the school systems started their holiday breaks early in an attempt to help curb the flu’s spread and allow teachers and students a chance to recover. Similarly, in the Midwest, high flu rates in Illinois and Ohio led some schools to close in order to “scrub down buildings” to aid infection control.
Although absentee rates as high as 30% among students, teachers, and administration may make the decision to close schools easier, lower absentee rates, such as the 17% experienced by one Georgia County, may make the decision a tough call. When other factors are added in—parents who may be unhappy about the sudden need to make childcare arrangements, the difficulty of scheduling makeup days, and the economic impact on an area—the question becomes downright tricky. Added to that is the mixed information on closure’s effectiveness to prevent disease spread: although some studies show closing schools effectively decreases infection rates in those school-age children, it can increase infection rates in other age groups. Similarly, children who are out of school may still participate in social activities, leading to increased infection rates anyway.
School administrators looking for guidance may have a hard time getting clear answers as well. During the 2009 H1N1 Influenza, the Centers for Disease Control (CDC) released a statement recommending that schools not close during the outbreak, but emphasized that the recommendation was “a guideline, and decisions should be made on local conditions.” For the 2009 H1N1 outbreak, about 700 schools closed, 50 of which were in New York City, which saw over 800,000 cases. Although that likely fits the recommendation of closing if a “local outbreak is especially intense,” Dr. Thomas Friedan (then New York City Health Commissioner, who made the decision to close NYC schools), later stated that closing was a “choice, not a necessity.” The CDC’s H1N1’s guidance recommended that in addition to hygiene measures, schools rely on parents to keep students home if they were feverish—yet another imprecise method with unreliable results.
In its Technical Report for State Local Public Health Officials and School Administrators for H1N1, the CDC provided more specific information to aid in the decision to close schools, be it preemptively (based on predictive disease modeling) or reactively (as schools in the South did this past winter). Either way, the CDC urged collaboration among decision-makers, and emphasized the need to consider the significant secondary effects on the community. The report makes two things clear: although school closures work best when implemented early in relation to the appearance of the flu virus and when used with other community measures (such as cancellation of team and community events), it is not a decision to be made hastily or lightly.
None of these recommendations or guidelines will likely help South Korea, as it faces tough decisions battling the MERS outbreak. However, the complexity of closing schools for infectious diseases not only underscores the need to identify and understand infectious diseases early, it underscores the need for proper planning and collaboration in order to ensure officials are able to protect the public health while preserving community continuity.