Infection and transmission risks of COVID-19 in schools and their contribution to population infections in Germany: A retrospective observational study using nationwide and regional health and education agency notification data

• Published in: PLoS medicine Vol. 19; no. 12
• Main Authors: Torben Heinsohn, Berit Lange, Patrizio Vanella, Isti Rodiah, Stephan Glöckner, Alexander Joachim, Dennis Becker, Tobias Brändle, Stefan Dhein, Stefan Ehehalt, Mira Fries, Annette Galante-Gottschalk, Stefanie Jehnichen, Sarah Kolkmann, Annelene Kossow, Martin Hellmich, Jörg Dötsch, Gérard Krause
• Format: Journal Article
• Language: English
• Published: Public Library of Science (PLoS) 01-12-2022
• ISSN: 1549-1277; 1549-1676

Background School-level infection control measures in Germany during the early Coronavirus Disease 2019 (COVID-19) pandemic differed across the 16 federal states and lacked a dependable evidence base, with available evidence limited to regional data restricted to short phases of the pandemic. This study aimed to assess the (a) infection risks in students and staff; (b) transmission risks and routes in schools; (c) effects of school-level infection control measures on school and population infection dynamics; and (d) contribution of contacts in schools to population cases. Methods and findings For this retrospective observational study, we used German federal state (NUTS-2) and county (NUTS-3) data from public health and education agencies from March 2020 to April 2022. We assessed (a) infection risk as cumulative risk and crude risk ratios and (b) secondary attack rates (SARs) with 95% confidence interval (CI). We used (c) multiple regression analysis for the effects of infection control measures such as reduced attendance, mask mandates, and vaccination coverage as absolute reduction in case incidence per 100,000 inhabitants per 14 days and in percentage relative to the population, and (d) infection dynamic modelling to determine the percentage contribution of school contacts to population cases. We included (a) nationwide NUTS-2 data from calendar weeks (W) 46-50/2020 and W08/2021-W15/2022 with 3,521,964 cases in students and 329,283 in teachers; (b) NUTS-3 data from W09-25/2021 with 85,788 student and 9,427 teacher cases; and (c) detailed data from 5 NUTS-3 regions from W09/2020 to W27/2021 with 12,814 cases (39% male, 37% female; median age 14, range 5 to 63), 43,238 contacts and 4,165 secondary cases for students (for teachers, 14,801 [22% male, 50% female; median age 39, range 16 to 75], 5,893 and 472). Infection risk (a) for students and teachers was higher than the population risk in all phases of normal presence class and highest in the early 2022 omicron wave with 30.6% (95% CI 30.5% to 32.6%) of students and 32.7% (95% CI 32.6% to 32.8%) of teachers infected in Germany. SARs (b) for students and staff were below 5% in schools throughout the study period, while SARs in households more than doubled from 13.8% (95% CI 10.6% to 17.6%) W21-39/2020 to 28.7% (95% CI 27% to 30.4%) in W08-23/2021 for students and 10.9% (95% CI 7% to 16.5%) to 32.7% (95% CI 28.2% to 37.6%) for staff. Most contacts were reported for schools, yet most secondary cases originated in households. In schools, staff predominantly infected staff. Mandatory surgical mask wearing during class in all schools was associated with a reduction in the case incidence of students and teachers (c), by 56/100,000 persons per 14 days (students: 95% CI 47.7 to 63.4; teachers: 95% CI 39.6 to 71.6; p < 0.001) and by 29.8% (95% CI 25% to 35%, p < 0.001) and 24.3% (95% CI 13% to 36%, p < 0.001) relative to the population, respectively, as were reduced attendance and higher vaccination coverage. The contribution of contacts in schools to population cases (d) was 2% to 20%, lowest during school closures/vacation and peaked during normal presence class intervals, with the overall peak early during the omicron wave. Limitations include underdetection, misclassification of contacts, interviewer/interviewee dependence of contact-tracing, and lack of individual-level confounding factors in aggregate data regression analysis. Conclusion In this study, we observed that open schools under hygiene measures and testing strategies contributed up to 20% of population infections during the omicron wave early 2022, and as little as 2% during vacations/school closures; about a third of students and teachers were infected during the omicron wave in early 2022 in Germany. Mandatory mask wearing during class in all school types and reduced attendance models were associated with a reduced infection risk in schools. Torben Heinsohn and co-authors investigate infection and transmission risks of COVID-19 in schools, school-level infection control measures, and their contribution to population infections in Germany. Author summary Why was this study done? Infection control policy for schools in Germany is sovereignty of the 16 federal states. A lack of evidence for measures in schools resulted in varying approaches to school infection control, in particular, masking and reduced attendance measures during the first year of the pandemic and beyond. Data for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in schools was limited to small regions and short time periods. What did the researchers do and find? We gathered data collected by national and regional government agencies on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) school infections and transmission, covering March 2020 to April 2022 and in total 3,534,778 cases in students and 340,429 in staff or teachers. The risk of getting infected was higher for students and teachers than the general population when schools were open with all students present. Strict masking and reducing student numbers were associated with a reduction in this risk. Students and teachers are more likely to pass on their infection in the household than the school. Their contacts in school were responsible for up to 20% of infections in the population during the early 2022 omicron wave and as little as 2% during school closures and vacations. What do these findings mean? When hygiene measures to reduce infections in schools are necessary including masking policies for students and teachers in all schools during class and reducing student numbers should be considered. Contribution of school contacts to overall transmission in the population is highly variable, ranging from 20% during the omicron wave with open schools to 2% during closures/vacations. Limitations include underreporting of cases, misclassification of school contacts, inaccuracies in contact tracing, and lack of data on individual person factors in grouped data analysis.