Prevalence of SARS-CoV-2 Infections Among Students, Teachers, and Household Members During Lockdown and Split Classes in Berlin, Germany | Global Health | JAMA Network Open | JAMA Network
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Figure.  Age-Stratified SARS-CoV-2 School Community Incidence in Berlin, Germany, in February and March 2021
Age-Stratified SARS-CoV-2 School Community Incidence in Berlin, Germany, in February and March 2021

Arrows indicate the time points of the cross-sectional assessment during lockdown (A, mid-February 2021) and split-class schooling (B, end of March 2021). Data were derived from the Berlin State Office for Health and Social Affairs.6

aTwice-weekly mandatory testing in schools with rapid diagnostic tests (RDTs).

Table.  Selected Characteristics of Students, School Staff Members, and Household Members in Berlin, Germany, in February and March 2021
Selected Characteristics of Students, School Staff Members, and Household Members in Berlin, Germany, in February and March 2021
1.
Ravens-Sieberer  U, Kaman  A, Erhart  M, Devine  J, Schlack  R, Otto  C.  Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany.   Eur Child Adolesc Psychiatry. Published online January 25, 2021. doi:10.1007/s00787-021-01726-5PubMedGoogle Scholar
2.
Ismail  SA, Saliba  V, Lopez Bernal  J, Ramsay  ME, Ladhani  SN.  SARS-CoV-2 infection and transmission in educational settings: a prospective, cross-sectional analysis of infection clusters and outbreaks in England.   Lancet Infect Dis. 2021;21(3):344-353. doi:10.1016/S1473-3099(20)30882-3PubMedGoogle ScholarCrossref
3.
Theuring  S, Thielecke  M, van Loon  W,  et al SARS-CoV-2 infection and transmission in school settings during the second COVID-19 wave: a cross-sectional study, Berlin, Germany, November 2020. Eurosurveillance. Accessed August 26, 2021. https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2021.26.34.2100184
4.
van Loon  W, Rössig  H, Burock  S,  et al  Emergence of SARS-CoV-2 B.1.1.7 lineage at outpatient testing site, Berlin, Germany, January-March 2021.   Emerg Infect Dis. 2021;27(7):1931-1934. doi:10.3201/eid2707.210845PubMedGoogle ScholarCrossref
5.
KIDSCREEN Group Europe. The KIDSCREEN Questionnaires—Quality of Life Questionnaires for Children and Adolescents. Handbook. Pabst Science Publishers; 2006. Accessed May 28, 2021. https://s2f1ad284f5ffc52e.jimcontent.com/download/version/1494315548/module/11487374212/name/KIDSCREEN_manual_English.pdf
6.
Berlin State Office for Health and Social Affairs. COVID-19 in Berlin, distribution by age group. Published April 5, 2020. Accessed May 20, 2021. https://www.berlin.de/lageso/gesundheit/infektionskrankheiten/corona/tabelle-altersgruppen-gesamtuebersicht/
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    Research Letter
    Infectious Diseases
    September 28, 2021

    Prevalence of SARS-CoV-2 Infections Among Students, Teachers, and Household Members During Lockdown and Split Classes in Berlin, Germany

    Author Affiliations
    • 1Institute of Tropical Medicine and International Health, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
    • 2Department of Pediatric Respiratory Medicine, Immunology, and Critical Care Medicine, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
    • 3Medical Directorate, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
    • 4Institute of Public Health, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
    JAMA Netw Open. 2021;4(9):e2127168. doi:10.1001/jamanetworkopen.2021.27168
    Introduction

    Children tend to bear a smaller proportion of the COVID-19 disease burden but are particularly affected by pandemic restrictions, including school closures.1 The occurrence of SARS-CoV-2 infection in school communities tends to be isolated and to produce few secondary cases.2,3 Between June 2020 and March 2021, we examined 24 school classes (12 primary and 12 secondary) across Berlin, Germany, on 4 occasions. In November 2020, there were 9 (2.7%), 2 (1.4%), and 14 (2.3%) SARS-CoV-2 infections among 338 students, 140 teachers, and 611 household members during the second pandemic peak, respectively (7-day incidence of 185 to 210 per 100,000). No secondary cases occurred among individuals in classes.3 After SARS-CoV-2 infections declined in early 2021, they increased again in mid-February and peaked by mid-April (Figure). In parallel, the SARS-CoV-2 B.1.1.7 variant gained predominance.4 Here, we present data observed with our cohort (1) at the end of February 2021, after a 2-month lockdown, and (2) at the end of March 2021, 2 to 3 weeks after schools resumed instruction with split classes half of the original size attending school on alternate weeks.

    Methods

    The details of this study were described previously.3 Classes comprising 327 students, 142 staff members, and 591 associated household members were tested for SARS-CoV-2 infection during lockdown between February 19 and 26, 2021. Split classes comprising 324 students, 133 staff members, and 591 associated household members were tested on March 25, 2021. Mandatory infection prevention and control measures for schools included an absence rule for symptomatic individuals, frequent ventilation, 1.5-m distancing, and face mask wearing. Rapid diagnostic tests (from Roche, Siemens, and Nal von Minden, among others) were distributed to schools by the Senate of Berlin for voluntary use. Illustrated self-swabbing kits (oropharynx, both nostrils; CoronaOne) were sent to participants and collected within 24 hours. Reverse transcriptase–polymerase chain reaction (GFE Blut) was used to determine SARS-CoV-2 infection. Participant symptoms and behavior were documented. In March 2021, we measured students’ health-related quality of life (HRQOL) by administering the KIDSCREEN-10 questionnaire for children. Individual scores were transformed into T scores. Low HRQOL was defined as 0.5 SD below the mean T score of (prepandemic) reference data for children.5

    This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Informed written consent and assent was obtained from all participants and their legal guardians in the case of minors. The Charité–Universitätsmedizin Berlin ethics committee approved the study.

    Results

    We obtained swabs from 1044 of 1060 participants (98.5%) during lockdown and from 898 of 1048 participants (85.7%) during split classes. In the latter period, 271 of 309 students (87.7%) and 101 of 123 staff members (82.1%) had attended school at least once in the preceding 14 days, with a median of 6 and 9 days (range, 1-11), respectively. Further characteristics are shown in the Table.

    Of 1044 participants who underwent testing during lockdown in February 2021, we detected 1 symptomatic adult household member with SARS-CoV-2 infection (0.1%; 95% CI, 0.0%-0.5%). Four weeks later in March 2021, 6 of 898 individuals with split classes had SARS-CoV-2 infection (0.7%; 95% CI, 0.2%-1.4%). Of these 6 individuals, 2 students and 3 household members had a known positive test result and/or were quarantined and 1 teacher was asymptomatic. The students and teacher with SARS-CoV-2 infection attended different schools.

    In March 2021, 73 of 180 students (40.6%) expressed moderate to very strong fear of infection (in response to the question “How afraid are you of contracting the coronavirus?”), 77 of 174 (44.3%) exhibited a low HRQOL score, 140 of 179 (78.2%) never or rarely saw friends, and 103 of 179 (57.5%) never or rarely played sports in the preceding 14 days. Computer gaming (96 of 179; 53.6%) and television/video (YouTube) watching (152 of 177; 85.9%) were common among students (Table).

    Discussion

    In early 2021, we detected only isolated SARS-CoV-2 infections, no clusters, and 1 school attendee with an infection. This low level of infection at schools confirms our previous data.3 Moreover, students’ decreased HRQOL scores and participation in leisure activities illustrate the deleterious outcomes associated with almost 1 year of pandemic restrictions. Ongoing work will further detail these outcomes. Berlin’s SARS-CoV-2 incidence pattern shows a rapid increase (Figure), particularly among children, 2 weeks postlockdown during split-class schooling in March 2021.6 Exponential growth in incidence began weeks earlier, although we cannot exclude an acceleration of SARS-CoV-2 infection as a result of school attendance. Other explanations include available rapid tests for students beginning in mid-March and increased SARS-CoV-2 transmission attributable to the B.1.1.7 variant. Limitations of our study include its small sample size, 2 cross-sectional time points, and voluntary participation potentially leading to selection bias. Our data support that school closures should be the last resort in controlling the SARS-CoV-2 pandemic.

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    Article Information

    Accepted for Publication: July 27, 2021.

    Published: September 28, 2021. doi:10.1001/jamanetworkopen.2021.27168

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 van Loon W et al. JAMA Network Open.

    Corresponding Author: Welmoed van Loon, MSc, Institute of Tropical Medicine and International Health, Charité–Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany (welmoed.vanloon@charite.de).

    Author Contributions: Ms van Loon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: van Loon, Theuring, Hommes, Mall, Kurth, Mockenhaupt.

    Acquisition, analysis, or interpretation of data: van Loon, Theuring, Hommes, Seybold, Kurth, Mockenhaupt.

    Drafting of the manuscript: van Loon, Mockenhaupt.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: van Loon, Kurth, Mockenhaupt.

    Obtained funding: Mockenhaupt.

    Administrative, technical, or material support: Hommes, Mall, Seybold, Mockenhaupt.

    Supervision: Seybold, Kurth, Mockenhaupt.

    Conflict of Interest Disclosures: Dr Kurth reported receiving research funds from the German Joint Committee and the German Ministry of Health and having received personal compensation from Eli Lilly and Company, Teva, TotalEnergies SE, and BMJ. No other disclosures were reported.

    Funding/Support: This study was supported by the Senate of Berlin.

    Role of the Funder/Sponsor: The Senate of Berlin had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Ravens-Sieberer  U, Kaman  A, Erhart  M, Devine  J, Schlack  R, Otto  C.  Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany.   Eur Child Adolesc Psychiatry. Published online January 25, 2021. doi:10.1007/s00787-021-01726-5PubMedGoogle Scholar
    2.
    Ismail  SA, Saliba  V, Lopez Bernal  J, Ramsay  ME, Ladhani  SN.  SARS-CoV-2 infection and transmission in educational settings: a prospective, cross-sectional analysis of infection clusters and outbreaks in England.   Lancet Infect Dis. 2021;21(3):344-353. doi:10.1016/S1473-3099(20)30882-3PubMedGoogle ScholarCrossref
    3.
    Theuring  S, Thielecke  M, van Loon  W,  et al SARS-CoV-2 infection and transmission in school settings during the second COVID-19 wave: a cross-sectional study, Berlin, Germany, November 2020. Eurosurveillance. Accessed August 26, 2021. https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2021.26.34.2100184
    4.
    van Loon  W, Rössig  H, Burock  S,  et al  Emergence of SARS-CoV-2 B.1.1.7 lineage at outpatient testing site, Berlin, Germany, January-March 2021.   Emerg Infect Dis. 2021;27(7):1931-1934. doi:10.3201/eid2707.210845PubMedGoogle ScholarCrossref
    5.
    KIDSCREEN Group Europe. The KIDSCREEN Questionnaires—Quality of Life Questionnaires for Children and Adolescents. Handbook. Pabst Science Publishers; 2006. Accessed May 28, 2021. https://s2f1ad284f5ffc52e.jimcontent.com/download/version/1494315548/module/11487374212/name/KIDSCREEN_manual_English.pdf
    6.
    Berlin State Office for Health and Social Affairs. COVID-19 in Berlin, distribution by age group. Published April 5, 2020. Accessed May 20, 2021. https://www.berlin.de/lageso/gesundheit/infektionskrankheiten/corona/tabelle-altersgruppen-gesamtuebersicht/
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