Risk for Severe COVID-19 Illness Among Teachers and Adults Living With School-Aged Children
Authors: Adam W. Gaffney, David Himmelstein, Steffie Woolhandler
Journal: Annals of Internal Medicine (2020)

Letters21 August 2020Risk for Severe COVID-19 Illness Among Teachers and Adults Living With School-Aged ChildrenFREEAdam W. Gaffney, MD, MPH, David Himmelstein, MD, and Steffie Woolhandler, MD, MPHAdam W. Gaffney, MD, MPHCambridge Health Alliance/Harvard Medical School, Boston, Massachusetts (A.W.G.), David Himmelstein, MDCity University of New York at Hunter College, New York, New York (D.H., S.W.), and Steffie Woolhandler, MD, MPHCity University of New York at Hunter College, New York, New York (D.H., S.W.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-5413 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Schools provide critical educational and health benefits to children, and reopening them facilitates parents', particularly mothers', return to work (1). Although children rarely have severe coronavirus disease 2019 (COVID-19) illness, they can transmit infection (2).Objective: To determine the prevalence of risk factors for severe COVID-19 illness among teachers and adults living with school-aged children.Methods and Findings: We analyzed nationally representative data from the 2018 National Health Interview Survey. We used the Centers for Disease Control and Prevention's criteria (3) to define “definite” and “possible” risk factors for severe COVID-19 illness, including differing severities of obesity, and tabulated their prevalence among 3 groups: employed adults other than teachers, adults employed as teachers, and adults living with school-aged (aged 5 to 17 years) children. We assessed differences in the prevalence of definite or possible risk factors among adults living with children according to the children's ages (5 to 10 years vs. 11 to 17 years), race/ethnicity, and family income using bivariate logistic regressions. Analyses were done with STATA/SE, version 16.1 (StataCorp), using weights and procedures that accounted for the survey's complex design.The National Health Interview Survey sample included 14 097 adults representative of 150.3 million U.S. nonteacher workers; 592 adults representative of 5.8 million primary, secondary, and special education teachers; and 5682 adults representative of 69.7 million adults living with school-aged children.Among teachers, 39.8% (weighted n = 2.32 million [95% CI, 1.98 to 2.66 million]) had definite and 50.6% (weighted n = 2.95 million) had definite or possible risk factors for severe COVID-19 illness (Table 1). Although only 0.7% had cancer, 27.9% had a body mass index (BMI) of 30 kg/m2 or greater, 4.2% had a BMI of 40 kg/m2 or greater, and 8.0% had a cardiac condition. The prevalence of most risk factors was similar among nonteacher workers, although more were smokers; 41.4% had any definite risk factors, and 55.8% had definite or possible risk factors.Table 1. Risk Factors for Severe COVID-19 Illness Among Teachers* and Adults Living in a Household With School-Aged ChildrenAmong the 69.74 million adults living with school-aged children, 41.0% (weighted n = 28.61 million [CI, 27.03 to 30.20 million]) had definite and 54.0% (weighted n = 37.7 million) had definite or possible risk factors, including 2.50 million who were older than 64 years, 4.67 million with heart disease, 4.84 million with type 2 diabetes, and more than 600 000 with cancer.The prevalence of risk factors was similar among adults living with younger versus older children (Table 2). Adults living with children in low-income households were more likely to be at risk than those in higher-income households, as were those residing with Black children; adults living with Asian American children or children of other races/ethnicities were at lowest risk.Table 2. Increased Risk for Severe COVID-19 Illness Among Adults Living in a Household With School-Aged Children, by Children's Age, Children's Race/Ethnicity, and Family Income (n = 5682)Discussion: About 40 million U.S. adults who work or live with school-aged children have definite or possible risk factors for severe COVID-19 illness, a number that excludes 4.4 million nonteachers working at schools and 1.6 million day care workers (Himmelstein DU. Unpublished data). Adults living with Black children and those living with children in low-income households are at especially high risk; teachers' risk seems similar to that of other working adults.By mid-March 2020, 107 nations had closed schools to help contain the COVID-19 outbreak (4); many that have suppressed the virus are now reopening them. In-person instruction is preferable for children's educational and social development, and school closures may adversely affect children's mental health, food security, and safety (1). Moreover, children rarely develop severe COVID-19 disease. However, as our findings indicate, school leaders must weigh these undoubted benefits against the risk to the adults who care for children, particularly older children who commonly transmit the infection (younger children are about one third as likely to cause household spread) (2). Both the risks and benefits of schools reopening are likely larger for poor and Black families.Our study has limitations. We could not identify school personnel other than teachers or day care workers in the National Health Interview Survey, nor could we identify some conditions identified as risk factors for severe COVID-19 illness, such as chronic kidney disease or thalassemia. Hence, our estimate of the number of adults at risk is likely too low. Our study data predated the COVID-19 pandemic, although substantial shifts in disease prevalence seem unlikely. Finally, different risk factors and different levels of obesity carry different levels of risk for severe COVID-19 illness (for example, a BMI ≥45 kg/m2 more than quintupled the risk for COVID-19–related death, whereas a BMI of 30 to 34 kg/m2 increased it by 26%) (5).Our findings underscore the need for careful consideration of and preparation for school reopenings this fall. The resumption of face-to-face instruction is critical for children's development, health, and welfare. However, without adequate safeguards, reopening schools could put millions of vulnerable adults at risk for severe COVID-19 illness.References1. American Academy of Pediatrics. COVID-19 planning considerations: guidance for school re-entry. Accessed at http://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools on 20 July 2020. Google Scholar2. Park YJ, Choe YJ, Park O, et al. COVID-19 National Emergency Response Center, Epidemiology and Case Management Team. Contact tracing during coronavirus disease outbreak, South Korea, 2020. Emerg Infect Dis. 2020;26. [PMID: 32673193] doi:10.3201/eid2610.201315 CrossrefMedlineGoogle Scholar3. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people with certain medical conditions. Accessed at www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html on 10 July 2020. Google Scholar4. Viner RM, Russell SJ, Croker H, et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. 2020;4:397-404. [PMID: 32272089] doi:10.1016/S2352-4642(20)30095-X CrossrefMedlineGoogle Scholar5. Tartof SY, Qian L, Hong V, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Ann Intern Med. 2020. doi:10.7326/M20-3742 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Daniel G. Arkfeld MDKeck, USC School of Medicine25 August 2020 What to do when your 8 month pregnant daughter who is teacher wants to go back to the classroom. It is with great and personal interest that I read this article by Gaffney et al since my daughter teaches first grade and is 8 months pregnant. At first I thought this was an easy since avoiding potentially virus infected asymptomatic children is a real risk of disseminated covid infections and even of Kawasaki like inflammatory responses in the newborn. However in discussing her plan I found out that she would like to teach the first graders in small PODS of 5 students each in person In that way she could prove proper education on basic subjects and maintain a safer work environment with masks and distancing. Unfortunately, her school district did not agree, and she is only doing virtual computer teaching. Disclosures: None Author, Article, and Disclosure InformationAuthors: Adam W. Gaffney, MD, MPH; David Himmelstein, MD; Steffie Woolhandler, MD, MPHAffiliations: Cambridge Health Alliance/Harvard Medical School, Boston, Massachusetts (A.W.G.)City University of New York at Hunter College, New York, New York (D.H., S.W.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-5413.Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Gaffney (e-mail, agaffney@gmail.com). Data set: Available at www.cdc.gov/nchs/nhis/nhis_2018_data_release.htm.Corresponding Author: Adam Gaffney, MD, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139; e-mail, agaffney@challiance.org.This article was published at Annals.org on 21 August 2020. 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