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    5 Comments for this article
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    Concerns About Accuracy of Given Short Study Time Period
    Jessie Schwartz, RN, MPH | None
    I would like to ask the authors why they decided to stop their data collection in May 2020, and if they think the massive spike in cases in the South and West this summer would change their results. It seems like the study data is too narrow to capture the results of school closures (i.e., they did not observe what happened when all schools were closed in the summer).

    Do the authors worry that they may have arrived at an erroneous conclusion, and/or that these conclusions could have vast policy implications that are particularly harmful to children? />
    Please see the Medscape article which discusses selection bias, sampling bias, and ascertainment bias as it relates to recent COVID-19 research (1).

    Thanks for your consideration!

    Signed,
    A Concerned Parent of 3 Public School Children

    REFERENCE

    1.  "COVID-19 Data Dives: The Banana Peel of COVID-19 Research" https://www.medscape.com/viewarticle/930681
    CONFLICT OF INTEREST: None Reported
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    Confidence Intervals are for Sample Data
    James Gundlach, PhD, Sociology UT Austin | Professor Emeritus, Sociology, Auburn Univ
    When you have population data, including count of number of actual deaths, you should not use confidence intervals. The confidence interval tells you the probable error in sample data estimating population data. When you have population data sample confidence intervals only obscure actual effects.
    CONFLICT OF INTEREST: None Reported
    Author Response To Comments
    Katherine Auger, MD, MSc | Cincinnati Children's Hospital Medical Center
    Ms. Schwartz: Thank you for your question. We were very purposeful in our study period selection. Had we extended the study past early May, it certainly would have increased our likelihood of modeling other changes (policy and behavioral) (i.e. non-school noise). Our goal was to construct models that isolated any potential effects associated with school closure to the extent possible given that we do not have data on things like increased hand-washing and masking. Thus, we focused on the immediate time period around school closure.

    Dr. Gundlach: Thank you for your careful reading of our manuscript. I believe
    you are referring to the "overall new cases (deaths) per 100,000" lines in Table 2. We do not have confidence intervals around those numbers because they are the actual number of observed cases (and deaths) in the entire United States during this time period (expressed as a rate per 100,000). These data are not extrapolated from population sampling--it is the US in its entirety. Yes, there is uncertainty regarding numbers of cases and deaths from COVID-19 but that is a larger issue related to testing availability and public health monitoring that is a challenge for all COVID-19 studies. 

    We did want to give the reader some sense of variability by state, so we added a second set of lines on observed data in the table right below these lines "New cases (deaths) per 100,000 residents per state." In these lines we present the median and the IQR by state.

    Best,
    Katherine
    CONFLICT OF INTEREST: None Reported
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    Shelter-in-place Household Dynamics
    Jack App, MPP | Retired, Math Professor, Irvine Valley College
    Did you consider that the principal impact of school closure was to force some working adults to shelter-in-place in order to provide childcare? Even the mobility of non-working parents would be impacted. Communities with families that consisted of one or two working adults and no older [>age 12] children would seem to have had a strong incentive to shelter-in-place during this period and thereby slow the spread of infection. Given that at this stage of the pandemic many fewer children than adults appear to have been infected, this de facto impact on adult behavior may have been the primary impact, not spread in or via school operations. Consequently, I am concerned that I can't find any family size or description data in your model.
    CONFLICT OF INTEREST: None Reported
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    Response to Dr. App
    Katherine Auger, MD, MSc | Cincinnati Children's Hospital Medical Center
    Dr. App: You raise an important question, which our study team has spent much time discussing. What is the mechanism by which closing schools could potentially impact COVID-19 cases and mortalities? Closing schools disrupts child-to-child interaction, child-to-adult and adult-to-child interaction within schools, as well as adult-to-adult interaction outside of schools. Parents must alter work schedules to care for children who are no longer in schools. It is impossible to know which of these disruptions would alter coronavirus transmission (likely all do to varying degrees). However, all of these changes are part of school closure.

    In our study we
    examined effects associated with school closure (all of the effects including the aspects of family disruption.) We have not thought of a way to analytically separate out the possible different mechanisms listed above. We also are not sure if one should try to disentangle these mechanisms as you cannot close schools without adult disruption.

    With regard to family size, household size would reflect not just the number of children in the household but also the number of adults. Household size is likely associated with crowding and poverty rates as well. In our analysis, we considered two related variables the percentage of children living in the state as well as the social vulnerability index which consists of measures of household composition and disability as well as housing type (crowding).
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    July 29, 2020

    Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US

    Author Affiliations
    • 1Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
    • 2James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
    • 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
    • 4Pediatric Research in Inpatient Settings Network, Cincinnati, Ohio
    • 5Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
    • 6Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
    JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.14348
    Key Points

    Question  Was statewide school closure associated with decreased incidence and mortality for coronavirus disease 2019 (COVID-19)?

    Findings  In this US population–based time series analysis conducted between March 9, 2020, and May 7, 2020, school closure was associated with a significant decline in both incidence of COVID-19 (adjusted relative change per week, −62%) and mortality (adjusted relative change per week, −58%). In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

    Meaning  There was a temporal association between statewide school closure and lower COVID-19 incidence and mortality, although some of the reductions may have been related to other concurrent nonpharmaceutical interventions.

    Abstract

    Importance  In the US, states enacted nonpharmaceutical interventions, including school closure, to reduce the spread of coronavirus disease 2019 (COVID-19). All 50 states closed schools in March 2020 despite uncertainty if school closure would be effective.

    Objective  To determine if school closure and its timing were associated with decreased COVID-19 incidence and mortality.

    Design, Setting, and Participants  US population–based observational study conducted between March 9, 2020, and May 7, 2020, using interrupted time series analyses incorporating a lag period to allow for potential policy-associated changes to occur. To isolate the association of school closure with outcomes, state-level nonpharmaceutical interventions and attributes were included in negative binomial regression models. States were examined in quartiles based on state-level COVID-19 cumulative incidence per 100 000 residents at the time of school closure. Models were used to derive the estimated absolute differences between schools that closed and schools that remained open as well as the number of cases and deaths if states had closed schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile.

    Exposures  Closure of primary and secondary schools.

    Main Outcomes and Measures  COVID-19 daily incidence and mortality per 100 000 residents.

    Results  COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100 000 population. School closure was associated with a significant decline in the incidence of COVID-19 (adjusted relative change per week, −62% [95% CI, −71% to −49%]) and mortality (adjusted relative change per week, −58% [95% CI, −68% to −46%]). Both of these associations were largest in states with low cumulative incidence of COVID-19 at the time of school closure. For example, states with the lowest incidence of COVID-19 had a −72% (95% CI, −79% to −62%) relative change in incidence compared with −49% (95% CI, −62% to −33%) for those states with the highest cumulative incidence. In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

    Conclusions and Relevance  Between March 9, 2020, and May 7, 2020, school closure in the US was temporally associated with decreased COVID-19 incidence and mortality; states that closed schools earlier, when cumulative incidence of COVID-19 was low, had the largest relative reduction in incidence and mortality. However, it remains possible that some of the reduction may have been related to other concurrent nonpharmaceutical interventions.

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