Pandemic Lessons: Answers to Covid-19 questions

Keep those classroom windows open.

Yes, it’s fall. Even a bright day has a chilly crispness in the air. And yes, opening a window isn’t energy efficient. It’s not good for the energy bills.

But if you want to keep schools open – and the students and staff safe – then keep those windows open, too.

That’s the advice shared by leading infectious disease experts for this first installment of an ongoing series, “Pandemic Lessons.” This week’s topic: Most schools have reopened, at least part time. What will it take to keep them open, especially in an upstate climate where cold weather will soon force outdoors classes inside?

Right now, teachers are creating airflow by opening windows and keeping doors open. But what about late fall and winter? Should we shut the windows and rely on masks and sanitizing to keep everyone safe? Or should we keep those windows cracked open and bundle up?

“Open the damn windows and let them wear their coats,” said Dr. George Rutherford, head of disease and global epidemiology at the University of California, San Francisco. “Keep the air moving. Get some air exchange.”

Rutherford is one of the leading epidemiologists in the United States; an important component of his work is researching and educating policymakers and the public on the ways Covid-19 spreads. Scientists like him thrive on questioning and critiquing the research of others –  it leads to smarter, solid conclusions. But on this point of the dangers of indoor air, the researchers we contacted – all of them considered top experts – seemed to agree.

“You’ve raised the trillion-dollar question,” said Dr. Michael T. Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. In a summer episode of his “Osterholm Update: Covid-19” podcast, Osterholm recommended schools run outdoor classes. But when we asked what to do during a Buffalo (or Minnesota) winter, Osterholm acknowledged that “one of the issues I’ve seen all along” is indoor air.

“I am very concerned,” said Osterholm, noting that since the pandemic began in spring, when the weather was warming, the issue resolved itself.

Temporarily.

“Unfortunately,” Osterholm said, “I’m afraid schools are going to be a place where we’re going to learn a lot about the respiratory transmission of this virus.”

But we’re six months into this pandemic. Don’t we know a lot already?

Yes – and no.

Six months – or nine months, dating back to when this particular coronavirus was identified in Wuhan, China – is not a long time to gain understanding of a new virus. Experts say it spreads through your respiratory system and enters the body through your eyes, nose or mouth in any of three ways:

• Heavier droplets emitted when someone talks, coughs, sneezes or breathes. These droplets may be loaded with a higher volume of virus because of their size, but they also tend to drop to the ground within 6 feet of the person who emitted them. Masks seem to be particularly helpful in preventing this type of spread.

• Surface contamination that happens when respiratory fluids end up on a desk, door handle or any other touchpoint. If someone touches the virus-covered surface and then rubs their eyes, nose or mouth, they could get infected. (Many researchers say this type of spread seems to be rare.)

• Aerosols, which are a microscopic mist of particles emitted by talking, breathing, sneezing and coughing. Because they are so light, aerosols tend to float – not quickly drop – and can move with the airstreams in a room.

Researchers are still trying to figure out how much aerosols contribute to Covid-19 transmission. Rutherford points to about two dozen “well-documented cases,” as he describes them, including a restaurant in China and a nursing home in the Netherlands. “Out of 25 million cases, we maybe have 24 cases where we can clearly say this was aerosol transmission,” he said.

But don’t take that as reassurance. There are plenty more instances, including in the United States, of outbreaks happening in restaurants and other settings. It’s difficult to conclusively point to aerosols as the reason — but they could be. That’s why schools – especially if they are poorly ventilated – could deliver a lesson we do not want.

Hold on. Aren’t masks supposed to protect us?

Yes, a good mask helps. In fact, some researchers hypothesize that masks are the reason mortality rates are dropping: By cutting down on the volume of virus breathed out and in, people who do get infected may be getting less-severe infections.

But masks don’t necessarily prevent illness.

We asked Osterholm about the risk level of a hallway crowded with students, most or all wearing face coverings. “We don't really know how well masks like this protect in that kind of setting,” he said, noting that “breathing air in is the real challenge we have, and how well face-cloth coverings reduce that is not yet known. When you're indoors, you're going to see increasing concentrations of virus in the settings where ventilation obviously is not continually adequate.”

Can’t a school simply get a good ventilation system?

Sure. Got $11 million?

That’s how much the Cleveland Hill Union Free School District spent on a capital project that upgraded its air handling units. That work was, fortuitously, completed just before the pandemic.

The Cleveland Hill system sits on the roof and trades 7,000 cubic square feet of fresh air every minute, making it unnecessary – and even counterproductive – to open windows. “I never thought I would enjoy the money that we spent on the air handler units,” said school Superintendent Jon MacSwan. But that system, along with adequate space and class sizes generally under 20 students, have allowed him to reopen school with confidence.

MacSwan knows that Cleveland Hill was lucky that the capital project finished last winter. “The timing of it was perfect,” he said. “That’s helped us a lot.”

How else can a school create air flow?

The idea is to get clean air — and broadly speaking, many schools don’t.

Dr. Joseph Allen, director of the Healthy Buildings Program at the Harvard T.H. Chan School of Public Health, told reporters in a recent media call that the minimum standard for a safe indoor environment is three air changes per hour.

But the average American school building, he added, “gets about half that.”

In that same call, Allen raised the bar for what schools should be trying to achieve now: “Four air changes is good,” he said. “Five is excellent. Six is ideal.”

Short of upgrading or replacing its ventilation system, a school can also purchase portable air cleaners for every classroom, Allen said.

Or they can open up.

Allen’s research team found that by opening windows even 6 inches, and opening doors, “you can get five, six, seven, sometimes over 10 air changes per hour.”

So that’s the easy and cheap, way. And chilly, too.

Rutherford, the doctor in San Francisco, offered up a tidbit from the 1918 influenza pandemic: “New York was the only large school district not to close during the 1918-1919 school year,” he pointed out. “They moved all their classes outdoors. And there are pictures of these kids with like three pairs of mittens on, sitting outdoors.”

You could do that. Or you could settle for blankets and coats and bundling up at desks. You’ll be cold, but you’ll breathe a little easier.

Note: In the coming weeks, we’ll probe some of the most vexing questions of living with Covid-19, from parenting decisions to leadership challenges to making schools work. We’ll talk to experts and distill the information here. If you have questions or topics you’d like to see explored, email toshei@buffnews.com or tweet @timoshei.

We’re not doing well.

Western New York’s positive-test rates for Covid-19 are topping 5%. That’s better than much of the country, but alarming in New York, which has managed to keep the virus spread largely under control through the summer and much of the fall.

On a Friday, Saturday and Sunday in early August, Western New York’s percentage of positive tests were 1.7%, 1.6% and 0.8%, according to state data. But this Friday, Saturday and Sunday, our positive rates were 4.3%, 4.8% and 5.3%. That’s markedly higher than most of the state, and on Monday, Gov. Andrew Cuomo announced that much of Erie County would be restricted as a microcluster yellow zone.

This installment of “Pandemic Lessons” explores what we’re doing wrong – and how we can get it right. 

Why are our numbers so high?

It’s impossible to pin it to a single reason, but here’s a good bet: We’re taking the 1% approach.

Or put another way: Too many of us are acting like it’s still summer, back when our test-positivity rates were at a comparatively comfortable 1-2% range. That means people are likely gathering and road-tripping as as they would have during those summer days. But it’s chillier now, and parties tend to move indoors, where the more stagnant airflow allows the virus to linger and build and get breathed in.

But there’s more to the answer.

In the summer, people in Western New York could slide by in unmasked and overlapped social bubbles because the prevalence of cases in the community was so low. “You can do some riskier types of activities, but you might get away with it because all the people around weren’t infected,” said Dr. Thomas Russo, chief of infectious disease at the University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences.

But when the numbers start rising, Russo added, it’s much more likely you’ll be interacting with someone who is infected. “And obviously,” he added, “if you're doing activities without masks, that's going to increase the likelihood that you will get infected.”

While it’s hard to pin down how outbreaks start, officials are largely saying K-12 schools aren’t to blame. What are schools doing right?

Schools aren’t perfect on this, and there can be a difference in Covid-19 protocols from one to the next. But schools that are doing coronavirus-era education right are sanitizing surfaces, controlling crowd sizes, creating ventilation by cracking open windows and monitoring the flow of hallway traffic.

But most of all, they are requiring masks – which scientists agree with increasing certainty are the No. 1 tool for stopping the spread. “That level of protection with the mask is probably going to be better than our first generation of vaccines – it’s going to be like 90%,” said Russo, who also noted that schools – especially with extracurricular activities and lunches, when masks are down, are likely “part of our driver” of rising numbers.

Masks are so politicized – they’re a significant point of stress – and now our kids are wearing them in class. Are we even seeing some of this contentiousness play out in schools?

Yes, in different parts of the country – although it’s early in the return to school to gauge the size and scope of the issue in educational settings.

Jonathan Schechter, an attorney with Gross Shuman P.C. in Buffalo, is the attorney for Niagara Charter School and has been monitoring mask-related lawsuits around the country. (He hasn’t seen any locally yet.)

In an interview with The News, Schechter pointed out the U.S. Supreme Court has reinforced political officials’ broad latitude in determining public health policy during the pandemic. Requiring masks in schools, then, can be considered “a function of public health and safety,” Schechter said. “(A) school's position is going to be, ‘Look, constitutionally, we have an obligation to make sure our students, our faculty and everybody is safe. So because everybody has to be safe, that is our legal grounds for forcing you to do this.’ ”

Most schools, Schechter added, are adopting policies that require students to learn fully at home if they refuse to wear a mask. That prompted at least one lawsuit to cite the famous Brown vs. the Board of Education case – which was decided in 1954. In that case, the Supreme Court ruled that racial segregation in schools is illegal.

In this case about masks, the lawsuit claims learn-at-home policies amount to “separate and unequal education.”

So while masks may be with us a while, so too, it seems, is the controversy that comes with them.

So, then, how do we return to normal?

Adjust our attitude.

Let’s turn to Dr. Michael T. Osterholm, a leading epidemiologist since the 1980s and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. In his book “Deadliest Enemy: Our War Against Killer Germs,” Osterholm writes about a virus that spreads across the globe, crashing economies, shutting down public events and triggering towering unemployment. He describes governments scrambling to stockpile supplies and develop vaccines.

He wrote that book in 2017 – and so he has a crystal-ball view shaped by research, data and a willingness to be blunt.

Osterholm was talking about how to navigate this school year, knowing that sports, activities and milestone events may not happen, and realizing that classes could shut down and go digital at any time. “Our job is to get the best out of this year that we can,” said Osterholm, who suggested three priorities:

1. Protect students, teachers and staff.

2. Help people who don’t have access to necessities like food that they would otherwise get in school.

3. Don’t blame. There will be families who keep their kids home. There will be families who pull their children from school but allow them to play sports – which to you, may not make sense – but to them, it does.

“The point is, how do we mesh all that up together?” said Osterholm, who President-elect Joe Biden named to his newly formed coronavirus task force. “That's where understanding has to come in. We can't look at this being good guys and bad guys. This is a bad virus and us.” 

What will it take for us to get it right?

Specifically, plan on the holidays at home. Write notes, send cards, log into Zoom.

But broadly? We need to change our mindset– and looking to Asia would be a good place to start.

Several days ago, Taiwan celebrated its 200th straight day without a Covid-19 case. It’s one of several Eastern countries that has managed to tamp down the virus. “It’s hard to argue with that data,” said Russo, who calls the Eastern-Western difference a “cultural phenomenon.”

“In the United States and Western Europe, we tend to be more egocentric and tend to be more about ourselves – individual rights and liberties,” he said. “Whereas Asian countries are much more community and family oriented, right? What’s best for family? What’s best for the community?”

Note: Do you have a topic or question you’d like to see explored in an upcoming installment of “Pandemic Lessons”? Send it to Tim O’Shei at toshei@buffnews.com or via Twitter (@timoshei). 

You’ve likely heard this advice so often that you can repeat it without thinking:

1. Wear a mask.

2. Social distance.

3. Sanitize.

It’s sound science and delivered with effective psychology, following the so-called “rule of three” principle that suggests humans remember information effectively in patterns of three.

But here’s the danger of advice that can be remembered almost mindlessly: You still have to think; you have to apply it to situations. Here in Western New York, with snow totals rising and temperatures dropping, that means making the science work indoors.

Heading into Christmas and the new year, this installment of “Pandemic Lessons” brings you advice from top scientists on how to keep your indoor spaces safe:

Can’t we just follow those oft-repeated basic rules and be safe?

You can, but you also need to realize that as scientists have learned more about how the coronavirus spreads, some rules have emerged as more urgent than others. For example, though the virus can be transmitted via contaminated surfaces, it’s mainly spreading through the air.

“We need to be spending more than half of our time and efforts and money on cleaning the air, rather than cleaning the surfaces,” said Dr. Lindsey Marr, an aerosol scientist at Virginia Tech who’s done groundbreaking research on the airborne transmission of viruses. “We call it surface hygiene theater: You make people feel safe, because you show that you're cleaning lots of things. But in reality, if you're ignoring the air, then you've missed the big problem.”

Marr and other air quality experts are acutely concerned about aerosols, the microscopic particles we emit when we breathe and talk. An infected person’s aerosols contain virus particles, and if those gather in a room, the other people will breathe them in and possibly become infected, too.

But cleaning the air is tricky. You can spray and wipe down a surface. You can wash your hands. You can even avoid touching your face. But you can’t “spray” the air – at least not safely – and you can’t avoid breathing. Experts note that air cleaning sprays contain chemicals that you don't want to inhale. 

OK, clean air is clearly important, but it sounds harder to get. How can you make it happen?

It’s a challenge, but there are multiple strategies you can use:

• Open windows. The essential advice throughout the pandemic is to avoid gathering – especially indoors – with people who live outside your household. But if you do, or if you’re in an office or school, aim for high ventilation by cracking open multiple windows, which exchanges indoor air for clean – albeit chilly – outdoor air.

For this, we can borrow from the advice given to schools that have reopened and seen minimal spread inside the building. In a conference call with reporters before schools opened in late summer, Dr. Joseph Allen, director of the Healthy Buildings Program at the Harvard T.H. Chan School of Public Health, suggested opening windows 6 inches. He said the minimum standard for a safe indoor environment is three air changes per hour, but the typical American school building “gets about half that.” But by opening windows, he added, a school can get double or even triple the minimum air changes per hour. Though the number of air changes will vary from building to building, and from a school or office to a home, you can apply the same principle anywhere.

Marr suggests investing in a carbon dioxide sensor. Since we exhale carbon dioxide, that device effectively hints at the concentration of aerosols in a space. “If the level of carbon dioxide builds up in the air,” she said, “that means you’re not getting enough ventilation.”

• Adjust your air system. If you’re working in a home or office with an HVAC (heating, ventilation, air conditioning) system, adjust it to bring in more outdoor air, rather than mostly recirculating indoor air, which could be contaminated. If your system can handle a filter with a higher MERV (minimum efficiency reporting value) rating, go for it. A MERV 13 filter is ideal, Marr said, because it can remove 80% of virus particles. A typical system, she added, would use a MERV 8.

• Buy a portable air cleaner. Much like a space heater warms a room, a portable air cleaner with a HEPA (high-efficiency particulate air) filter removes more than 99% of virus and other particles, Marr said. “You just need to have enough of them, and a high enough flow rate in the room so that the air is actually passing through that frequently enough that you can remove virus from the air,” she added, noting that limiting the occupancy of a room – and thus having fewer breathing beings in one spot – keeps aerosols down. Masks, too, will limit the aerosols that escape from the mouths of the people who are in the room.

• Get a humidifier — and set it right. Humidifiers are doubly helpful. They are healthy for your immune system: A study by Yale University researchers showed that humidifiers can combat transmission of Covid-19 by bolstering your body’s antiviral response. They also help clear virus from the air — but you need to set it in the right range, said Marr, whose research shows that 40% to 60% humidity is “the sweet spot” where the virus “decays quickly.” If the air gets too saturated with moisture, in the 80% to 90% range, then the virus sits in a respiratory droplet – “its own microenvironment,” Marr said, that resembles what it had in the body. If the air gets too dry, she added, “then the virus actually survives pretty well, like freeze-dried food.”

What are longer-term benefits to better ventilation?

Better indoor air quality is better health.

Marr, who studies these things and tracks other research, pointed out multiple benefits: Kids do better on tests. Workers are more productive. Since flus and colds are transmitted similarly to Covid-19, she said, “We could see a reduction in the number of cases of those other diseases even after we manage to get control of Covid-19.”

Which strategy is the best?

None are failsafe, not even in combination.

Cracking the windows, plugging in a purifier and humidifier doesn’t offer a free pass to host a holiday dinner for 10. But if you want to treat the air with the same care as we do surfaces, these investments are sound ones now and even beyond this pandemic, since they’ll help address airborne issues with a variety of viruses. “People should get both an air purifier and a humidifier,” said Dr. Angela Rasmussen, a Georgetown University-affiliated virologist, in an interview with The Buffalo News this fall.

How do we pull it all together?

Marr likens managing indoor spaces to “being close to a smoker.”

“You don't want to be close to a smoker – you can breathe in lots of smoke,” she said. “As you get farther away, you breathe in less smoke, but that smoke doesn't stop at 6 feet.”

You can distance yourself to 10 feet – “That’s fine, that’s better,” Marr said – but if you’re in that room for a while, and it’s poorly ventilated, you’re still not going to avoid breathing in the smoke.

“That's why we need the distance plus we need the masks plus we need attention to ventilation and avoiding crowds,” Marr said. “So each one of those things help some, but none of them is 100% protective. But when you combine them, then you can get better than 90% risk reduction of the chances of transmission.”

Note: Do you have a topic or question you’d like to see explored in an upcoming installment of "Pandemic Lessons?” Send it to Tim O’Shei at toshei@buffnews.com or via Twitter (@timoshei).