This study quantified child-care obligations for US health-care workers arising from school closures and estimated the trade-off between reduced COVID-19 transmission and the role of health-care labor in cumulative mortality. The study describes scenarios in which school closures, in the absence of other child-care options, could either increase COVID-19 mortality by reducing the health-care labor force or decrease COVID-19 mortality by reducing cases. At this time, there is great uncertainty about whether school closures will ultimately reduce or increase COVID-19 mortality.
The coronavirus disease 2019 (COVID-19) pandemic is leading to social (physical) distancing policies worldwide, including in the USA. Some of the first actions taken by governments are the closing of schools. The evidence that mandatory school closures reduce the number of cases and, ultimately, mortality comes from experience with influenza or from models that do not include the effect of school closure on the health-care labor force. The potential benefits from school closures need to be weighed against costs of health-care worker absenteeism associated with additional child-care obligations.
For this modelling analysis, the authors used data from the monthly releases of the US Current Population Survey to characterize the family structure and probable within-household child-care options of US health-care workers. They accounted for the occupation within the health-care sector, state, and household structure to identify the segments of the health-care workforce that are most exposed to child-care obligations from school closures. They then used these estimates to identify the critical level at which the importance of health-care labor supply in increasing the survival probability of a patient with COVID-19 would undo the benefits of school closures and ultimately increase cumulative mortality.
Between January, 2018, and January, 2020, the US Current Population Survey included information on more than 3.1 million individuals across 1.3 million households. The authors found that the US health-care sector has some of the highest child-care obligations in the USA, with 28.8% (95% CI 28.5–29.1) of the health-care workforce needing to provide care for children aged 3–12 years. Assuming non-working adults or a sibling aged 13 years or older can provide child care, 15.0% (14.8–15.2) of the health-care workforce would still be in need of child care during a school closure.
The authors estimated that, combined with reasonable parameters for COVID-19 such as a 15.0% case reduction from school closings and 2.0% baseline mortality rate, a 15.0% decrease in the health-care labor force would need to decrease the survival probability per percent health-care worker lost by 17.6% for a school closure to increase cumulative mortality.
Their model estimates that if the infection mortality rate of COVID-19 increases from 2.00% to 2.35% when the health-care workforce declines by 15.0%, school closures could lead to a greater number of deaths than they prevent.
In summary, school closures come with many trade-offs, and can create unintended child-care obligations. The results from this analysis suggest that the potential contagion prevention from school closures needs to be carefully weighted with the potential loss of health-care workers from the standpoint of reducing cumulative mortality due to COVID-19, in the absence of mitigating measures.
