Abstract
BACKGROUND: Several studies have reported SARS-CoV-2 outbreaks in schools, with a wide range of secondary attack rate (SAR; range: 0-100%). We aimed to examine key risk factors to better understand SARS-CoV-2 transmission in schools. METHODS: We collected records of 35 SARS-CoV-2 school outbreaks globally published from January 2020 to July 2021 and compiled information on hypothesized risk factors. We utilized the directed acyclic graph (DAG) to conceptualize risk mechanisms, used logistic regression to examine each risk-factor group, and further built multirisk models. RESULTS: The best-fit model showed that the intensity of community transmission (adjusted odds ratio [aOR]: 1.11, 95% CI: 1.06-1.16, for each increase of 1 case per 10 000 persons per week) and individualism (aOR: 2.72, 95% CI: 1.50-4.95, above vs. below the mean) was associated higher risk, whereas preventive measures (aOR: 0.25, 95% CI: 0.19-0.32, distancing and masking vs. none) and higher population immunity (aOR: 0.57, 95% CI: 0.46-0.71) were associated with lower risk of SARS-CoV-2 transmission in schools. Compared with students in high schools, the aOR was 0.47 (95% CI: 0.23-0.95) for students in preschools and 0.90 (95% CI: 0.76-1.08) for students in primary schools. CONCLUSIONS: Preventive measures in schools (e.g., social distancing and mask wearing) and communal efforts to lower transmission and increase vaccination uptake (i.e., vaccine-induced population immunity) in the community should be taken to collectively reduce transmission and protect children in schools.