Rush to Reopen Buys COVID-19 More Time

March 4, 2021
Kevin Kavanagh, MD

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.

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 239 top scientists from 33 countries. 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 was airborne. 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 droplets with coughing.”

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 household contacts. 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.) Han M.S., et al, reported in JAMA Pediatrics 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 10- to 19-year-olds…”

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 Michael Osterholm, MD. As reported in STAT, 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 SARS-CoV-2. The letter stated:

“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, that’s the best.”

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 severe COVID-19.

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 bus driver. 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 reopening.

School staff concerns are supported by a recent CDC article which reported frequent transmission in schools where proper precautions are not taken. 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.