While school closures reduce case transmission of COVID-19, they may also reduce the capacity of a strained health care labor force.
While health departments around the world are scrambling to deploy appropriate response measures to address the coronavirus disease 2019 (COVID-19) pandemic, decisions intended to reduce transmission introduce complex social burdens that public health officials may not anticipate.
For example, the debate on community mask use in the United States requires weighing a complicated array of costs and benefits. Positions have shifted from earlier in the pandemic toward more public health support for community mask use, but the limited supply of personal protective equipment remains a concern.
The investigators of a recent study published in The Lancet Public Health developed statistical modeling which raises difficult questions about the pros and cons of school shutdowns, which have been deployed across the globe. The study team identified a threshold at which the substantial reduction in childcare coverage risks reduced health care workforce capacity, in turn leading to a higher incidence of COVID-19 mortality than would occur without school closures.
To conduct the modelling analysis, the study team used data from monthly releases of the US Current Population Survey to establish the family structures and likely child care options of health care workers.
The survey data included information on more than 3.1 million individuals across 1.3 million households between 2018 and 2020.
The investigators assessed sectors, states, and household structures to identify sections of the health care workforce most vulnerable to child care obligations due to school closures. They then compared the impact of reducing case transmissions with the impact of reducing an essential labor force.
“We highlight 2 pathways through which school closures could affect pathogen-induced mortality. School closures… can affect mortality through reduction in cases…including cases of health care worker infection (pathway 1), and through a reduction in the health care labor force that treats sick patients and prevents mortality (pathway 2),” the study authors wrote.
The investigators identified the threshold at which a reduction of health care labor would have a greater impact on the survival probability of a patient with COVID-19 than the reduction of case transmissions through school closures.
Survey data revealed that 28.8% of health care workers had child care obligations for a child between 3 and 12 years of age. The study team also identified that 15% of workers have households without a non-working adult or sibling aged 13 years or older who could care for younger children.
The study team also found that 6.8% of health care workers live in 1-parent households, a greater proportion than workers in all other major industry classifications.
The health care worker roles with the highest share of single-parents were nursing, psychiatric, and home health care staff, medical assistants, and licensed practical and licensed vocational nurses. These roles make up 30% of the health care workforce and are often the workers who provide infection control for the elderly in nursing homes.
The study team ultimately modeled that—assuming a 15% case reduction from school closings and a 2.0% baseline mortality rate—there is a point at which school closures would lead to a greater number of deaths than they prevent.
The labor dynamics they identify remain a challenge within other parameters, but the mortality threshold occurs when the COVID-19 mortality rate increases from 2% to 2.35% due to a reduction in the health care labor force.
It is too soon to know for certain what the long-term impact of many COVID-19 interventions will be, but it is likely the strain on health care workers during this time will be immense.
Whether the dynamic identified in the model actually reaches the threshold at which school closures increase mortality or not, the particular vulnerability of the US health care workers to conflicts between child care and participation in the labor force is important to consider.
“The US health care system appears disproportionately prone to labor shortages from school closures, particularly among those healthcare workers providing infection control in nursing homes” study author Jude Bayham, PhD, professor at Colorado State University, said in a press release.
"These potential health care workforce shortages should be a priority when assessing the potential benefits and costs of school closures, and alternative child care arrangements must be part of the school closure plan."