COVID-19 Infection Rates and Mitigation in U.S. Child Care Programs: 

A Natural Experiment of Critical Implications for Reopening Child Care & Public Schools

Walter S. Gilliam• Yale University •May 19, 2020

As states begin reopening businesses, child care programs that closed near the beginning of the COVID-19 pandemic in the U.S. will have to reopen to provide necessary child care for returning workers. This includes child care programs for young children, school-age summer programs, and eventually K-12 schools. Unfortunately, considerable research shows that child care programs and schools are significant contributors to viral spread;[1],[2] children from homes where an infected individual lives may pass the infection to child care providers and other children who then return to their own homes and communities to further spread the infection.[3],[4] Indeed, child care programs and schools (more than just about any other setting) can contribute significantly to community spread, which is why they were closed during the pandemic in the first place.[5],[6] On the other hand, without adequate child care programming, parents cannot return to work and businesses cannot reopen. 

CRITICAL QUESTIONS

Critical questions exist as to how best to reopen these child care programs. Do child care programs (both center- and home-based) contribute to COVID-19 spread? If so, to what degree? Do various infectious disease control practices in child care settings (e.g., frequent handwashing and surface disinfecting, personal protection for child care providers, and daily symptom screening) reduce the spread of COVID-19? If so, how much do these practices help, and which practices work best? When a COVID-19 illness is discovered in the program, should the entire program close for a period of time, or just the room where the illness was discovered? How likely is it that the child care providers will become ill and unable to work, and how many substitute providers will be needed to keep programs open? What is the likelihood that others living in the homes of these child care providers will themselves become ill when a provider brings COVID-19 home and into their communities? Will child care providers, who often work for very little pay and with uncertain access to healthcare themselves, even feel comfortable enough to return to work, or will they be too worried about illness and access to disinfectants, personal protection equipment, and other supplies needed to keep themselves and the children in their care safe? 

STUDY RATIONALE

Fortunately, we do not need to enter blindly into reopening child care programs, summer programs, and K-12 schools. Many of these questions are answerable, but would require an immediate data collection effort across a very large number of child care programs which includes those that were and were not open through the early months of the COVID-19 pandemic. When most all child care programs in the U.S. closed, many remained open. More specifically, many home-based child care programs (where the number of children was under many states’ gathering limits) remained open, and many center-based programs quickly reopened to provide child care for the children of essential workers. (See our Interactive COVID-19 Child Care Map for estimating the amount of child care needed for essential workers.[7])

This created the conditions for a fortuitous yet unplanned natural experiment comparing COVID-19 spread among child care workers in programs that remained open during the beginning of the pandemic versus those that closed. In other words, compared to child care workers who quickly stopped providing child care, were child care workers who continued providing child care more likely to contract COVID-19, more likely to suffer significant complications due to COVID-19, and more likely to have spread it to their own family members and close contacts? If so, this would suggest the degree to which child care itself contributed to the spread of COVID-19 and how much it may contribute during mass reopening. Within the programs that remained open, were there any specific practices that significantly reduced the spread of COVID-19 within their child care program and to others within close contact to the providers?

These findings are of critical importance to the safe reopening of child care programs and K-12 schools. If findings suggest that provider-to-community COVID-19 spread and symptom severity were no worse in open programs than in closed programs, this would provide confidence for reopening, and may allow child care providers and parents to feel less stress in returning to work. Conversely, if findings suggest significantly greater COVID-19 community spread through open child care centers, this would provide critical information regarding the need for greatly enhanced safety precautions, greatly reduced enrollment rates, or delayed or staggered reopening. Without knowing these answers, we are at a great disadvantage in terms of informed planning regarding the most effective COVID-19 safety procedures and supplies, potentially necessary enhanced substitute provider pools, and health and mental health supports. If we do not reopen child care programs and schools correctly, community infection and hospitalization rates may drastically increase, and the child care programs and schools would likely have to close anyway for quarantine. 

METHODS & UNIQUE OPPORTUNITY

We propose conducting one of the largest occupational epidemiology studies ever attempted. The play is to email a Qualtrics survey link to child care providers in programs (home- and center-based) that remained open or quickly reopened during the COVID-19 pandemic versus demographically-matched providers in programs that closed. Survey time is 12-20 minutes. Surveys would be emailed to providers and completed anonymously online. Confidentiality will be assured, and data will be maintained securely and de-identified. 

The survey will be emailed to about 556,000 to 880,000 child care providers from across the nation. Child Care Aware of America (CCAoA) will provide access to about 24,000 child care providers from across the nation, of which about 15,500 are child care providers who have contacted CCAoA for information, and about 10,000 are child care providers who have remained open during the COVID-19 pandemic and were requesting assistance (80% overlap between these two groups). Additionally, between 532,000 and 857,000 child care provider contacts will be provided by state child care workforce registries supported by the National Workforce Registry Alliance (NWRA). Currently, about state registries representing about 532,000 providers are participating, and the remaining state registries representing the other 325,000 are currently considering participation. The existence of a large dataset of providers, including those known to be open during the COVID-19 pandemic, is critical in making this important study possible. A large sample in the tens of thousands is needed, given the nature of the planned data analyses in this project and the need to map provider data to known community rates of COVID-19 spread. 

Survey items will include the following elements: basic demographic information about the program, the provider, and children (for both statistical representativeness and to assess issues of racial disparity in COVID-19 spread); program zip code (to allow data to be linked to known rates of COVID-19 spread in the surrounding community); data on numbers of staff and children; rate of COVID-19 symptom expression in the providers, other staff, and children; whether anyone in the program tested positive for COVID-19; COVID-19 health susceptibility factors (age, diabetes, respiratory conditions, etc.) of the providers and their family and close contacts; rate of COVID-19 symptom expression and positive testing in the providers’ families and close contacts; methods of COVID-19 infectious disease control used in the open programs, access to necessary disinfecting supplies and personal protective supplies (gloves, masks, aprons) and confidence that these supplies will be available in the future; access to health and mental health supports and personal health care; symptoms of stress and depression; and other similar variables. 

TIMELINE

This project must move on a very fast timeline in order to provide maximally useful findings. Because large numbers of child care programs are likely to reopen by June, it is essential to start data collection soon in order to obtain a baseline using programs that had remained closed. Therefore, a very aggressive timeline is planned. Data collection should happen between May 22 and June 1. Data analysis will be conducted during the first week of June. Findings will be submitted for expedited peer review by June 8, released as soon as possible, and used to generate recommendations for safest possible reopening of child care and schools. 

PROJECT TEAM

REFERENCES

[1] Barrón-Romero, B. L., Barreda-González, J., Doval-Ugalde, R., Zermeño-Eguia, J., & Huerta-Peña, M. (1985). Asymptomatic rotavirus infections in day care centers. Journal of Clinical Microbiology, 22(1), 116-118.

[2] Hebbelstrup Jenson, B., Jokelainen, P., Nielson, A. C. Y., Franck, K. T., Holm, D. R., Schønning, K., Petersen, A. M., & Krogfelt, K. A. (2019). Children attending date care centers are a year-round reservoir of gastrointestinal viruses. Scientific Reports, 9:3286. https://doi.org/10.1038/s41598-019-40077-9

[3] Cordell, R., Pickering, L., Henderson, F. W., & Murph, J. (2004). Infectious diseases in childcare settings [conference summary]. Emerging Infectious Diseases, 10(11): e9. doi: 10.3201/eid1011.040623_04; PMCID: PMC3329018. http://dx.doi.org/10.3201/eid1011.040623_04

[4] Jaing, X., Dai, X., Goldblatt, S., Buescher, C., Cusack, T. M., Matson, D. O., & Pickering, L. K. (1998). Pathogen transmission in child care settings studied by using a cauliflower virus DNA as a surrogate marker. Journal of Infectious Diseases, 177, 881-888.

[5] Danon, L., Read, J. M., House, T. A., Vernon, M. C., & Keeling, M J. (2013). Social encounter networks: Characterizing Great Britain. Proceedings of the Royal Society B, 280: 20131037. http://dx.doi.org/10.1098/rspb.2013.1037

[6] Lu, M. (2020, April 20). These are the occupations with the highest COVID-19 risk. Geneva: World Economic Forum. https://www.weforum.org/agenda/2020/04/occupations-highest-covid19-risk/

[7] Available at Yale School of Medicine (covid.yale.edu/innovation/mapping/childcare/) and Child Care Aware of America (www.childcareaware.org/coronavirus/child-care-essential-workers-coronavirus-outbreak/)