COVID-19 Cases and Transmission in 17 K–12 Schools

Wood County, Wisconsin, August 31-November 29, 2020

Amy Falk, MD; Alison Benda; Peter Falk, OD; Sarah Steffen, MMP; Zachary Wallace; Tracy Beth Høeg, MD, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2021;70(4):136-140. 

In This Article

Discussion

This study, involving students and staff members in 17 K–12 schools in five rural Wisconsin districts under district and statewide mask mandates, found high teacher-reported student masking compliance. Among 5,530 students and staff members, 191 COVID-19 cases were reported. Only seven (3.7%) of these cases were associated with in-school transmission, all in students. Despite widespread community transmission, COVID-19 incidence in schools conducting in-person instruction was 37% lower than that in the surrounding community.

Children might be more likely to be asymptomatic carriers of COVID-19 than are adults.[4] In the present study, the absence of identified child-to-staff member transmission during the 13-week study period suggests in-school spread was uncommon. This apparent lack of transmission is consistent with recent research,[5] which found an asymptomatic attack rate of only 0.7% within households and a lower rate of transmission from children than from adults. However, this study was unable to rule out asymptomatic transmission within the school setting because surveillance testing was not conducted.

Student masking compliance was reported to exceed 92% throughout the course of the study. Older children were reported to be equally compliant with masking as younger children. High levels of compliance, small cohort sizes (maximum of 20 students), and limited contact between cohorts likely helped mitigate in-school SARS-CoV-2 transmission and could be responsible for the low levels of transmission detected in schools. Investigation of 191 school-related COVID-19 cases in students and staff members suggested that most transmission occurred outside of required school activities. This finding is consistent with recently reported data suggesting limited transmission within schools.[6]

Some school districts throughout the country have set thresholds for reopening based on the percentage of positive test results in the community (e.g., Virginia: 10%, California: 8%).[7,8] The percentage of positive COVID-19 test results ranged from 7% to 40% in the community, and confirmed COVID-19 cases within schools were few. These findings suggest that attending school where recommended mitigation strategies are implemented might not place children in a higher risk environment than exists in the community. Having children in a monitored school setting might increase adherence to mask compliance, and cohorting can help minimize exposures for children and adults. In-person schooling for children has numerous health and societal benefits, especially for children and parents of lower socioeconomic status.[9]

The findings in this report are subject to at least seven limitations. First, mask use was assessed using a survey that was not validated, dependent on voluntary teacher response and subject to recall and social desirability biases.[10] The actual mask-wearing rate might have been different because only approximately one half of teachers participated in the study. Teachers with lower masking compliance in their cohort might have been less likely to complete the survey, which limits the reliability of this measure. Second, lack of data about masking compliance among staff members might also lead to a reported masking compliance that differed from actual masking compliance among all persons in the study. Third, it was not possible to determine the specific roles that mask-wearing and other disease mitigation strategies played in the low rate of disease spread, and information on school ventilation systems was not obtained. Fourth, because schools did not perform infection screening of staff members and students, the prevalence of asymptomatic spread could not be determined. However, recent serological survey data from a school setting found asymptomatic spread to be minimal.†† Fifth, sources of infection among identified cases were detected through contact tracing, which is less accurate than is genomic sequencing. Sixth, rural schools might differ in important ways from those in more densely populated areas. For example, the capacity to achieve physical distancing in schools might differ if classroom size and outdoor space in rural schools is different from that in suburban or urban schools. However, all the classes and lunch periods in this study were held indoors, as would be consistent with most urban settings. Finally, the ethnic makeup of this rural population was predominantly non-Hispanic White, and the results of this study might not be generalizable to other rural or nonrural school populations.

In a setting of widespread community SARS-CoV-2 transmission, few instances of in-school transmission were identified among students and staff members, with limited spread among children within their cohorts and no documented transmission to or from staff members. Only seven of 191 cases (3.7%) were linked to in-school transmission, and all seven were among children. Mask-wearing among students was reported by teachers as high, which likely contributed to low levels of observed disease transmission in these 17 K–12 schools. Although asymptomatic transmission is possible, this study demonstrated that, with precautions in place, in-school transmission of SARS-CoV-2 appeared to be uncommon in this rural Wisconsin community, despite up to a 40% positive SARS-CoV-2 test rate in the surrounding county.

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