What is the evidence for transmission of COVID-19 by children in schools? A living systematic review

Abstract

ABSTRACTBackgroundIt is of paramount importance to understand the transmission of SARS-CoV-2 in schools, which could support the decision-making about educational facilities closure or re-opening with effective prevention and control measures in place.MethodsWe conducted a systematic review and meta-analysis to investigate the extent of SARS-CoV-2 transmission in schools. We performed risk of bias evaluation of all included studies using the Newcastle-Ottawa Scale (NOS).Results2,178 articles were retrieved and 11 studies were included. Five cohort studies reported a combined 22 student and 21 staff index cases that exposed 3,345 contacts with 18 transmissions [overall infection attack rate (IAR): 0.08% (95% CI: 0.00%–0.86%)]. IARs for students and school staff were 0.15% (95% CI: 0.00%–0.93%) and 0.70% (95% CI: 0.00%–3.56%) respectively. Six cross-sectional studies reported 639 SARS-CoV-2 positive cases in 6,682 study participants tested [overall SARS-CoV-2 positivity rate: 8.00% (95% CI: 2.17%–16.95%)]. SARS-CoV-2 positivity rate was estimated to be 8.74% (95% CI: 2.34%–18.53%) among students, compared to 13.68% (95% CI: 1.68%–33.89%) among school staff. Gender differences were not found for secondary infection (OR: 1.44, 95% CI: 0.50-4.14, P= 0.49) and SARS-CoV-2 positivity (OR: 0.90, 95% CI: 0.72-1.13, P= 0.36) in schools. Fever, cough, dyspnea, ageusia, anosmia, rhinitis, sore throat, headache, myalgia, asthenia, and diarrhoea were all associated with the detection of SARS-CoV-2 antibodies (based on two studies). Overall, study quality was judged to be poor with risk of performance and attrition bias, limiting the confidence in the results.ConclusionsThere is limited high-quality evidence available to quantify the extent of SARS-CoV-2 transmission in schools or to compare it to community transmission. Emerging evidence suggests lower IAR and SARS-CoV-2 positivity rate in students compared to school staff. Future prospective and adequately controlled cohort studies are necessary to confirm this finding.