The Icelandic Directorate of Health is Wrong — The Evidence for Closing Schools in a Pandemic is Strong
COVID19 cases are growing exponentially in Iceland, a nation with one of the highest cases per capita. We are still early, yet as the rate continues to accelerate, it is apparent that the tactics being used by the Directorate of Health are not working. It is time they adopted more aggressive prevention and mitigation measures. There is a direct association between COVID19’s exponential growth and a rapid, continued overload of the healthcare system. Not employing all evidenced-based interventions, such as school closures, only ensures exponential growth of the virus and a failure to save the healthcare system from an overload.
School closures are more effective than reactive quarantines or banning public gatherings according to Christakis. “If you wait for the case to occur, you still have wound up closing the school, but now you’ve missed the opportunity to have the real benefit that would have accrued had you closed the school earlier.”
This virus is more contagious than the 2003 SARS outbreak and the seasonal influenza, and it is not to be taken lightly. As we live our lives and go to work or school, we pass by and interact with countless people. This is a virus that spreads through droplets of saliva, can live on mostly all surfaces for days, and even free floats in the air for hours. It is transmitted farther in cold and dry air. It cannot be contained by quarantine alone, as we could never fully account for all the places that a virus is left by a contagious individual. And this is especially true as research indicates most people infected with COVID19 are highly contagious without symptoms for days, if ever.
“Flattening the curve” is a difficult aim, especially in a heavily resource constrained nation (for example, limited availability of hospital beds, respirators) and while there are massive global shortages of necessary medical supplies. For instance, all nations around the world are unable to keep the supply of respirators adequate and the shortage is real. We have seen the “prices of surgical masks have increased sixfold, N95 respirators have tripled in cost and protective gowns cost twice as much,” said Dr. Tedros A. Ghebreyesus of the World Health Organization. “Global stocks of masks and respirators are now insufficient to meet the needs of WHO and our partners”. With “delays of four to six months in supply… The world is facing severe disruption in the market for personal protective equipment (PPE). Demand is up to 100 times higher than normal, and prices are up to 20 times higher. This situation has been exacerbated by widespread inappropriate use of PPE outside patient care.” The Icelandic healthcare system will inevitably suffer from the effects of such a shortage.
To offer a hard-stop date of when this once-in-a-century virus will peak should make every person suspicious. Not only does this date differ substantially with leading epidemiologists around the world, it is only a couple of weeks after the rate of new cases just begins to grow more exponential. One individual, who may not show symptoms, can be contagious for weeks. If they are not getting tested or on strict self-isolation, then they are most likely infecting others at a high rate, especially given the highly contagious nature of SARS-CoV2 (the virus that causes COVID19). On average, COVID19 patients take about 7 days from exposure to show symptoms (range 2–14 days), and a meaningful percentage of carriers can spread the disease for 2–4 days before they are symptomatic.
In epidemiology, we can focus on varying types of prevention (for example, vaccinations, school closures, workplace closures) and mitigation (for example, quarantining an individual and everyone that crossed their path over a week or two period, reactive containment). At this time, the Directorate of Health is doing little of each and the effects are showing: exceptionally high rates of infection and rates that are accelerating. If the tactics would be working, we would be seeing sharp declines or stagnation. Yet, as most of society carries on as usual and asymptomatic individuals are turned away from tests by the government, it is time to boost our approach and follow decades of data-driven nonpharmaceutical interventions that other nations are utilizing with success. This includes nation-wide school closures, workplace closures and lockdowns. Rates are more exponential than initially believed, with each person, on average, infecting between 4.7 and 6.6 individuals. On the other hand, and primarily thanks to deCODE, testing has been more than most countries can boast. But this has stalled and, as the virus spreads, people will need to repeat a test, especially as lockdowns, mandatory closures and curfews are not in place. Testing is but one tool, and for this tool to be so effective that it shadows any other tactic, such as school closures or strict social isolation, it would need to be sweeping, enabling all citizens to get tested immediately and throughout the epidemic until it is almost eliminated.
The Directorate of Health has said on multiple occasions that there is no evidence for school closures. They are wrong. There is overwhelming evidence for school closures and overwhelming evidence for closing them as early as possible. And this includes before a case is identified. In Iceland, though we are seeing few closures, this has only been in response to a positive case and not in the context of proactive measurements.
Nicholas Christakis, the Goldman Family Professor of Social & Natural Science at Yale University, nails this on the head. “If the epidemic is occurring around your school, you know that it is going to strike the school. And so if you’re prepared to close the school when it arrives at your school, it makes much more sense to close when it is near the school. We know from past epidemics of multiple types of viruses that school closure works. We know that it interrupts adult transmission even if the kids are not vectors. Here, it’s likely that kids are vectors.”
It is important to reemphasize that children are a significant vector for spreading this virus. Those that are asymptomatic (no symptoms) or with very low symptoms are vectors, as well. While estimates vary, research shows that upwards of 80% of all infected people are without symptoms or with very low symptoms. Even if an individual will eventually show symptoms, they are contagious for many days and sometimes weeks before the body reacts with cold symptoms. What this means is that for long periods, contagious people of all ages are walking around stores, going to school or work, and visiting family and friends. As one of the single most infectious viruses of the last century, this is bad news and for everyone.
People of all ages are being hospitalized and dying from this. A new analysis finds that among 508 patients hospitalized, 38% were under the age of 55. The likelihood of children spending all day together, coming from different homes, and spreading the virus to each other is exceptionally high, especially with one of the most contagious infectious diseases we have seen in 100 years. Children that would normally not catch this if they were out of school and in a society of lockdown, as they would not be in an environment of viral exposure, are now completely in an environment to catch this from other asymptomatic children. This is enabling the virus to leap from one home to the next. But it doesn’t stop there. We then need to add in the child’s extended family, their parents’ workplace, and the list goes on. It is then just a waiting game of “who in this large web of social connection will show symptoms first?” It’s a question that can take weeks to get an answer to. Then, as each person can infect many people, we are very easily seeing exponential growth. Requiring that a child is both (a) symptomatic and (b) has been in direct contact with a confirmed case of COVID (not just a person in quarantine), in order for a child to be tested will only enable the spread of the virus. Even if children are less likely to develop severe symptoms, children are spreading it rapidly. And it is clear that this problem worsens when the government is not currently allowing tests of those that are asymptomatic.
Evidence is clear from a growing and overwhelming number of studies from Japan, Italy, China, the UK, Mexico, and the US — just to name a few. The conclusion is that school closures reduce the total number of cases and delay the peak of epidemics, and the earlier the better. The range of evidence supporting school closures is abundant and extends back decades. This tactic helped reduce infection significantly.
Marco Ajelli, computational epidemiologist, carries this support further. “There is scientific evidence that closing schools can buy time and delay the peak of an epidemic. And it’s really important to gain time at the moment,” he says, “because if you have a lot of people that get infected all at the same time, the hospitals and ICUs have not enough hospital beds.”
A 2007 study, “Nonpharmaceutical Interventions During the 1918–1919 Influenza Pandemic,” published in the Journal of the American Medical Association looked at the impact that “nonpharmaceutical interventions,” specifically school closures, had on the influenza pandemic. Almost all of the cities eventually resorted to school closures. However, the study found that cities that closed schools earlier and kept them shut longer had better results in containing the spread of influenza, which included delays in the time to peak mortality, reductions in the magnitude of the peak mortality, and decreases in the total mortality burden. All very good things, especially in a resource-constrained society. The study also found that the most successful closures were those that lasted throughout the peak infection period.
As Christakis stated in an interview with Science Magazine, “Proactive school closures — closing schools before there’s a case there — have been shown to be one of the most powerful nonpharmaceutical interventions that we can deploy. If school closures are going to work most effectively, they need to be for months, not weeks.” Christakis continued, “St. Louis closed the schools about a day in advance of the [1918] epidemic spiking, for 143 days. Pittsburgh closed 7 days after the peak and only for 53 days. And the death rate for the epidemic in St. Louis was roughly one-third as high as in Pittsburgh. These things work.”
School closures are more effective than reactive quarantines or banning public gatherings according to Christakis. “If you wait for the case to occur, you still have wound up closing the school, but now you’ve missed the opportunity to have the real benefit that would have accrued had you closed the school earlier.”
It is one issue to disagree with the large body of literature and an incredible consensus among the world’s most leading epidemiologists, virologists, and immunologists, and microbiologists, but it is another to claim — as the Directorate of Health has done — that the benefits of closures do not outweigh the economic costs. There will be costs of closing schools for extended periods, as was seen in H1N1 outbreaks globally, and especially if children are not adequately homeschooled and parents are unable to work from home. However, as a severe pandemic, one with high rates of mortality, infection and significant complications, research suggests that the benefits of closing schools outweigh the direct and indirect economic costs of closures. To indicate that the costs resulting from the diminished quality of life for potentially thousands of people, the costs associated with deaths that could range in the hundreds very easily, and the innumerable expenditures to society (for example, healthcare costs, disability and critical illness costs, etc.) are somehow “less” than the the costs of school closures and getting this outbreak under true control is simply bad medicine and foolish. If closures affect those working in healthcare, which is where most research indicates as being the most sensitive aspect of closures, then it is the responsibility of the government to provide support to those professionals so that they may continue providing our nation with an invaluable service.
With systemic school closures, strict social distancing, more stringent quarantine and case-containment practices, mass testing of all (symptomatic and asymptomatic), Iceland could be a case study of how to respond to the worst global pandemic in a century. Nations all over the western world are closing schools as a primary prevention measure; they are no longer waiting for the first case. Systemic closures are part of an inevitable response trajectory for a responsible nation and it is time for Iceland to follow the best practices recommended by leading experts in infectious disease outbreaks, especially as Icelandic epidemiologists have no experience with a pandemic of this magnitude. When asked to comment on Iceland, just days before almost 100 more cases were added in a day, Christakis said “As an island, with a low COVID prevalence and a rich democracy, Iceland would be singularly positioned to take steps to limit the consequences, if it acts properly.” It’s time to act properly.
