Table 1.

Summary of Evidence of Impact of Physical Distancing in School Settings

Study/Country	Setting	Study Type	Distancing Intervention	Simultaneous Interventions	Results	Data Source
Netherlands [61, 64]	Primary schools & child care facilities	European Centre for Disease Prevention and Control (ECDC) report, nationwide surveillance	Children ≤12 y did not have to distance 1.5 m from each other or adults; children 13–18 y did not have to distance from each other but had to distance from adults	Masking not recommended	After schools re-opened May 11, 2020, no increase in reproductive number or significant outbreaks, with moderately high notification rates. Children ≤17 y represent 7.3% of cases between Jun 1 and Aug 23, though they comprise 20.7% of the population. No deaths.	National Institute for Public Health and the Environment (RIVM), The European Surveillance System (TESSy)
Iceland [61]	Child care institutions & primary care schools	ECDC report, nationwide surveillance	No physical distancing rules; no limitations in activities including sports & music; schools kept open during pandemic	Masking not recommended	Rates of infection in children <15 y remained low compared with rates in older age groups throughout spring term as of Jul 2020.	TESSy
Ludvigsson et al. [63, 100], Sweden	Schools & preschools (ages 1–16)	Cohort study, followed all children admitted to ICUs in Sweden, Mar 1–Jun 30, 2020	Physical distancing was recommended (unclear distance); schools kept open during pandemic	Masking not recommended	Low incidence of severe COVID-19 among school children. Among 1.95 million children, 15 had severe COVID-19 requiring ICU admission (1 per 130K).	Swedish Intensive Care Registry
Zimmerman et al. [39], USA	North Carolina K-12 school districts	Cohort study, investigated COVID-19 infection in districts with >90K students & staff open for 9 wk of in-person instruction, Aug 15–Oct 23, 2020	6-ft distancing	Mandatory masking for children ≥5 y	773 community-acquired infections documented. Via contact tracing, health department staff determined 32 school-acquired infections. Within-school infections were rare, with no child-to-adult transmission.	North Carolina Department of Health and Human Services
Yung et al. [101], Singapore [62]	Educational settings in Singapore	Cohort study, nationwide surveillance, Feb–Mar 2020	Students spaced 3–6 ft apart	K-2 children in clusters	Identified only 3 potential transmission incidents in 3 separate educational settings.	Ministry of Health Singapore
Macartney et al. [35], Australia New South Wales [102]	25 schools & early childhood care settings (ECEC)	Cohort study, evaluated SARS-CoV-2 transmission, Jan 25–Apr 9, 2020; schools encouraged distanced learning Mar 23	Physical distancing unspecified	Advised to consider reduction in class size	In 15 schools & 10 ECEC settings, 12 children & 15 adults attended while infectious with 1448 contacts. 18 secondary cases were identified (attack rate 1.2%). Transmission rates were low.	New South Wales Department of Health

Society guidance: Centers for Disease Control [20]: space seating/desks ≥6 feet apart when possible; World Health Organization [19]: physical distance ≥1 m; American Academy of Pediatrics [22]: desks should be placed ≥3 feet apart and ideally 6 feet apart.

Abbreviations: AAP, American Academy of Pediatrics; CDC, Centers for Disease Control and Prevention; COVID-19, coronavirus disease 2019; ECEC, early childhood care settings; ECDC, European Centre for Disease Prevention and Control; ICU, intensive care unit; RIVM, National Institute for Public Health and the Environment; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TESSy, The European Surveillance System; WHO, World Health Organization.