Kevin Kavanagh, MD

It is easy for lawmakers to enact and lift mandates, but they appear to be largely disconnected with public behavior and completely ignored by the SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Communities have focused their attention on opening schools. This is not an easy task since we all agree that our children are our future, and both their education and safety is of paramount importance. How to balance these two has generated heated community debate.

With community COVID-19 rates falling, it is appropriate that we prepare to open schools but much needs to be done. Most follow the droplet precautions’ mantra of: “Wear a cloth mask, social distance at 6 feet and all will then be fine. It is a scientific fact.”

Nothing could be further from the truth. Quite simply, this virus is aerosolized, meaning it is airborne. I really thought this had been decided last July when a letter was sent to the World Health Organization (WHO) by 329 top scientists from 

. But although agencies responded by recognizing airborne spread in some of their statements and webpages, their recommendations on controlling spread and reopening of businesses and schools largely did not.

In October of 2020, the National Academy of Science summarized the data on aerosolization of SARS-CoV-2 and presented strong evidence that the virus 

. Pointing out that aerosol formation has been found to take place with larger particles ranging in size up to 100 μm. These particles can travel farther than 6 feet and accumulate in a room, with a half-life of approximately 1.1 hours. And that: “These aerosols and droplets are produced by breathing, talking, and coughing, with talking associated with aerosols and the fast-settling 

Many areas of our nation are reopening schools with far too little strategies to prevent spread. The contribution of children to viral spread has been consistently downplayed but solid epidemiological studies have said otherwise. An October 2021 study from South Korea observed that school age children age 0 to 9 years spread the virus to 5.3% of household contacts and age 10 to 19 years to 18.6% of 

. However, all asymptomatic patients might not have been identified in this study. This caveat is of importance, since asymptomatic and mildly symptomatic disease are common in children. (And it should also not be forgotten that children do die of COVID-19 and can also develop Multisystem Inflammatory Syndrome in Children (MIS-C), along with other long-term sequelae.) 

 that 22% of children were asymptomatic carriers (throughout the entire study) and 25% were presymptomatic. Overall, 66% of children had unrecognized symptoms after diagnosis. These findings were confirmed by Davies N.G., et al. who reported that “clinical symptoms manifest in 21% (95% credible interval: 12–31%) of infections in 

With the new administration in Washington, D.C., and the appointment of a stellar transitory scientific COVID-19 task force before the election, many had hoped for greater emphasis on airborne transmission along with greater protection of frontline workers, patrons and students.

However, upon taking office President Biden dissolved the COVID-19 task force which was composed of many notable scientists including past BARDA Director Richard Bright, PhD, and CIDRAP Director and epidemiologist 

, the reason was according to Zeke Emanuel: “We decided that, well, we don’t have to be an official body. We can just get together and share our understanding of what’s happening, and people have various outlets to make that understanding effective.”

On February 15, 2021, one of these outlets was utilized. A letter was sent to the White House and the Centers for Disease Control and Prevention (CDC) from 12 of our top scientists, including Bright and Osterholm, which stressed the need for greater attention on preventing aerosolized spread of 

“For many months it has been clear that transmission through inhalation of small aerosol particles is an important and significant mode of SARS-CoV-2 virus transmission.” And that the “CDC guidance and recommendations do not include the control measures necessary for protecting the public and workers from inhalation exposure to SARS-CoV-2. Most recommendations from other agencies are also out of date.” The letter stated that the use of respirators (e.g. N95 masks) should be standard for all patient contacts, even non-COVID-19 diagnosed patients; and that crisis stop-gap advisements such as the resterilization of N95 masks need to be discontinued. The same protections need to exist for other frontline workers, including grocery workers, and there needs to be enhanced indoor ventilation.

In a NJ.com editorial, similar concerns were echoed by past Obama OSHA Director David Michaels, PhD, also a signer of the letter, who stated “We’ve known for nearly a year that COVID is airborne—yet aside from hospitals, few workplaces acknowledge that the virus can hang in the air,” and that “distancing is not always adequate; we know that people who are exposed at distances far greater than 6 feet have gotten sick. If you can make sure the virus is not in the air, 

Thus, as schools reopen, far too little attention is being placed on the spread of SARS-CoV-2. Buildings need to be healthier with increased clean air exchanges and air sanitization. Not only are parents being placed at a high risk from SARS-CoV-3 outbreaks in schools but 24% of teachers are themselves at high risk for developing 

And in Lexington, Kentucky, only 4 days after opening schools, 4 students and 1 staff member tested positive for SARS-CoV-2, necessitating quarantining 55 students, 1 employee and 1 

. Teachers are demanding vaccinations, and other frontline workers are similarly hesitant to return to work. Lexington is also experiencing a school bus driver shortage which is threatening 

School staff concerns are supported by a recent CDC article which reported frequent transmission in schools where proper precautions 

. In one Georgia school district, from December 2020 to January 2021, 9 clusters of COVID-19 spread occurred. The clusters involved 13 educators and 32 students in 6 elementary schools. These were young children, whom some believe do not spread COVID-19. There was spread from teachers to students and students to teachers. Nine of the index cases were teachers and 5 were students. Most concerning was that there was spread back to the home, with 18 of 69 (26%) tested household members being positive for COVID-19. This school district appeared to have poor social distancing and mask utilization was less than 100%.

All of the above raises concern for the safety of teachers, students, and their families. There needs to be a shift from droplet precaution standards to airborne spread standards and we need to invest in the safety of our frontline workers. Infrastructure changes in our schools are required so proper social distancing can take place, and air sanitization and air circulation increased. But most importantly, for all of this to take place, the CDC needs to articulate firm and harmonized advisements which are consistent across all materials, recommendations and webpages. Until this happens, there will not be a demand for N95 masks and air sanitization units. Manufacturing will not gear up production and pathogens will continue to spread. We need to enact these reforms not only for COVID-19 and the next pandemic, but for other endemic dangerous pathogens. Our children deserve better than the status quo.

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There needs to be a shift from droplet precaution standards to airborne spread standards and we need to invest in the safety of our frontline workers.

Rush to Reopen Buys COVID-19 More Time

The US Centers for Disease Control and Prevention (CDC) has just released guidance on the opening of schools during the coronavirus disease 2019 (COVID-19

. This has come after recent reports of increased safety in schools as compared to the community. But with high rates of community spread, “safer” does not mean “safe.” The CDC has made numerous suggestions and advisements, but the statement that caught my eye was:

“Schools that are open for in-person instruction (either fully open or hybrid) may decide to remain open even at high (red) levels of community transmission. These decisions should be guided by information on school-specific factors such as mitigation strategies implemented, local needs, stakeholder input, the number of cases among students, teachers, and staff, and school experience.”

I fear that instead of giving clear guidance that this statement may punt the decision to the local level, which will result in a non-standardized random approach to this pandemic, especially in areas of our nation which have not yet fully accepted the seriousness of COVID-19. Many of these areas are rural and leaders are not consistently wearing masks and frequently mitigate the pandemic.

The argument that preventative strategies need to be tailored to the needs and resources of local communities, along with a one-size-does-not-fit-all approach, may placate political pressures, but 

. You need to do what you need to do to control the disease. It needs to be clearly stated what needs to be done and if a community cannot comply and wants to open schools, then the parents need to be informed of the increased risks to students. Recommendations should not be changed to reassure families of a degree of safety which does not exist.

The CDC described five mitigation strategies as “key” and “essential to safe delivery of in 

“Universal and correct use of masks.”

“Handwashing and respiratory etiquette.”

“Cleaning and maintaining healthy facilities.”

“Contact tracing in combination with isolation and quarantine, in collaboration with the health department.”

But the guidance states that masks and physical distancing should be prioritized and cohorting or podding is recommended. This is confusing, since how can you prioritize two factors but have all 5 being essential?

Diagnostic testing is described as an additional prevention measure, stating: “Some schools may also elect to use screening testing as a strategy to identify cases and prevent secondary transmission” But frequent, (three times a week) screening of our athletes has been key to the opening of professional sports. Our students deserve the same safety precautions as professional athletes. Having students in small cohorts and with the performance of pod testing will make this possible. The use of pool testing which would allow the widespread surveillance and effective contact tracing, but it has all but disappeared from the narrative. It needs to be implemented in our schools.

Not only will testing and contact tracing be expensive, but so will physically distancing. Many of our classrooms are small and have a large number of students packed into them. It is not possible to physically distance students 6 feet apart. This is one of the reasons why I feel a hybrid structure should be incorporated into the curriculum. A hybrid schedule will allow small class sizes along with more personalized student contact. High-risk teachers could then be assigned to teach the virtual cases. Almost 25% of teachers are at high-risk for 

, and that was before the new more infectious and 

Far too little attention has been placed on increasing complete air exchanges and air sanitization in schools. It was evident early last year that aerosolization of SARS-CoV-2 was an important mode of spread, as described in research calculating the R0 of SARS-CoV-2 

 and from detailed reports of spread in a 

 should have been implemented to provide abundant and proper PPE. Instead, strategies were implemented for droplet precautions. At first the public was even advised to only social distance and not wear masks. And many frontline workers were given cloth masks, even when their degree of exposure required N-95s.

In early August, Health Watch USA(sm) called for better ventilation and air 

, with both high volume air flow and UV lighting for sanitation (central or stand alone ceiling units). Attention to air quality has been made even more imperative with the recent report from the National Academy of Sciences on 

. This report has updated much of our research and now describes the size of particles capable of aerosolization as being less than 100 um, as opposed to “traditional thinking” of particles less than “5 um.” And that breathing, talking, and singing can produce particles 

. The viral half-life was reported to be approximately 1.1 hours, and the good news is that UV light “greatly decreases viral stability.”

The CDC has stated, in-person learning may have to be prioritized over extracurricular activities. I believe this translates to the fact that heavy breathing and shouting of indoor contact sports will readily aerosolize and spread the virus and that these activities should be curtailed, especially during the emergence of these more infectious strains.

In addition, crowded hallways are problematic for avoidance of aerosolized pathogens. Possibly having teachers, as opposed to students, change classrooms would minimize transmission.

Pandemics are transformative, but in schools, smaller class sizes and healthier buildings are desperately needed regardless of the SARS-CoV-2 pandemic. Our children deserve better than class sizes over 20 and for too many, dilapidated inner-city buildings whose windows no longer open.

We should not repeat the mistakes of last year with ill-advised recommendations regarding masks and not testing of asymptomatic carriers, which appeared to be driven more by resource availability than public safety.

I feel the CDC needs to take a pathogen centered approach at stopping the spread of diseases. It is their responsibility to delineate what is needed to stop a pathogen, regardless of the resources available. It is up to other agencies and communities to decide if they wish to invest in the needed resources. If the CDC does otherwise, it will provide an excuse for inaction and even greater public harm may occur.

Frequent, (three times a week) screening of our athletes has been key to the opening of professional sports. Our students deserve the same safety precautions as professional athletes.

Viewpoint: CDC’s School Reopening Plan Gets an ‘F’

One of the most disturbing reports, which has largely gone unnoticed by the news media, was released on December 18, 2020 by the Health Service Journal (HSJ, Wilmington Healthcare). HSJ analyzed England’s National Health Service Data regarding hospital-acquired SARS-CoV-2 infections. SARS-CoV-2 is the virus that causes COVID-19 and unfortunately HSJ found that hospital-acquired infections (HAIs) are not uncommon, estimated to cause almost 1 in 4 hospital 

. The NHS metric considers any COVID-19 case diagnosed 8 days or more after admission an HAI. The United Kingdom also has a more infectious strain of the virus (B.1.1.7) than is commonly found in the United States.

Information has not been widely available in the United States regarding COVID-19 HAIs. The metric used in the USA is even more restrictive than the one used in the United Kingdom. The U.S. metric defines a COVID-19 HAIs as the: “Total current inpatients with onset of suspected or laboratory-confirmed COVID-19 fourteen or more days after admission for a condition other than 

If one considers that the average incubation period for SARS-CoV-2 is 

 and the average hospital stay in the United States is 

, this metric is next to useless. It will at best detect only a very small minority of cases. A more accurate metric would define cases which occur after 5 days as an HAI, which would better create a balance between false positive and negative cases. And the metric should count cases which occur for a period of 5 days after the patient leaves the facility. Again, creating a balance between false positive and negative cases.

With the CDC projecting that the UK variant will become the dominant strain in the US by March, it is imperative that we bolster our strategies to safeguard both 

With the CDC projecting that the UK variant will become the dominant strain in the US, it is imperative that we bolster our strategies to safeguard both staff and patients.

Some have postulated the increase in infectivity of the UK strain to an increased ability to attach to cells or to more viruses being reproduced by the infected cells. Recently sources have released data that the UK variant may be more lethal, possibly up to 30%, than our current variant infecting 

. Thus, it is plausible that the UK Variant’s increased infectivity is related to the shedding of more viruses into the environment by infected individuals.

Other possible mechanism’s for the UK variant’s increased spread is either greater survivability in the environment or an increased ability to aerosolize. Thus, we need an increased commitment and enhanced strategies to prevent spread. This includes all health care workers becoming vaccinated. You owe it to yourselves, your family, and your patients to receive the vaccine. The increase in infectivity also raises concern regarding the importance of spread by fomites. Hence, environmental cleaning needs to have strict and comprehensive protocols. All segments of our society, including frontline health care workers, need better personal protective equipment and N95 masks (without exhalation valves). Facilities of all types (including schools and retail establishments) need to increase complete air exchanges and air sanitization. Testing needs to be increased for staff and patients. We also need to eliminate, whenever possible, outpatient waiting rooms. And implement strict social distancing (not having chairs next to doors and areas of traffic flow). Finally, we need “data for action.” We need to have mandatory reporting of worker and patient acquisition of SARS-CoV-2 and the development of COVID-19 with metrics to provide us the most accurate estimate of cases so we can effectively plan and allocate resources.

We need to have mandatory reporting of worker and patient acquisition of SARS-CoV-2 and the development of COVID-19 with metrics to provide us the most accurate estimate of cases so we can effectively plan and allocate resources.

Problem: COVID-19 Hospital-Acquired Infections 

This morning I awoke to a report from Public Health of England, that the United Kingdom variant of SARS-CoV-2 has mutated again, and now it may be resistant to monoclonal antibodies along with possibly making the vaccines less 

. The UK variant developed the same mutation that the Brazilian and South African variants use to evade the body’s immune system.

This news comes after a long line of setbacks. I was hoping that the pandemic would go away in the summer after the lockdown. Then we had the severe surge in August which was to be the last; only being dwarfed by cases and deaths in our 

. Finally, there was a glimmer of hope, life-saving vaccines were becoming available and shots were going into arms. Even if the initial vaccines required 2 shots, it was worth it. But the virus struck back and mutated, making taking a booster necessary.

Now this, the same vaccine evading mutation is popping up all over the world, making the availability of booster even more urgent. But in this news, there may be a silver lining.

So how is there good news? Simply the fact that 3 different viruses with 3 different lineages came up with the same mutation to evade natural immunity and the vaccines. And initial reports are that it only partially evades the vaccines, they will still be effective. Thus, this is not even an optimal mutation.

In order to evade the vaccines and the body’s immunity, the virus has to evolve a mutation which will prevent a myriad of different antibodies from attaching and killing it while at the same time still be able to attach to the ACE2 enzyme receptor site. This is a tall order.

The fact that all 3 of these lineages came up with the same mutation, means that a single vaccine or booster shot may be able to neutralize, or at last have some activity against all of these strains.

And one needs to ask, why did these viruses not come up with different mutations? After all they do not plan the mutations, they evolve by random chance. Maybe the answer is that this random amino acid combination is possibly the last major mutation the virus can produce without changing its ability to enter the cells or its infectivity. Yes, there was MERS and SARS, so it is possible to see another iteration of this virus, but MERS and SARS were much more lethal, asymptomatic carriage was not common and these epidemics burned out, they were easier to control.

So, after a long string of disappointments and bad news, maybe this is the beginning of the end, and if we do see another even greater surge caused by these variants, maybe that will be the last if we all get vaccinated. And of course, we do not have to wait for a “booster” to the Pfizer and Moderna vaccines. If we all follow public health advice by wearing masks and social distancing, we have the power to stop future surges from taking place.

The good news? The fact that 3 different viruses with 3 different lineages came up with the same mutation to evade natural immunity and the vaccines. And initial reports are that it only partially evades the vaccines.

Kevin Kavanagh, MD

Articles

Rush to Reopen Buys COVID-19 More Time

Viewpoint: CDC’s School Reopening Plan Gets an ‘F’

Problem: COVID-19 Hospital-Acquired Infections

Beginning of the End? Some Hopeful COVID Developments