Q&A: Infection Preventionists Should Head Back to School

Infection preventionists are needed to help schools reopen properly, says Kevin Kavanagh, MD, a member of Infection Control Today®’s Editorial Advisory Board. Kavanagh worries that the push to reopen schools may be setting society up for a new wave of coronavirus disease 2019 (COVID-19). And even before COVID-19 hit, Kavanagh points out, schools were not safe havens for children. They’re more like germ factories. “Our schools in many areas are just plain dying, their infrastructure is crumbling,” says Kavanagh. “Their windows don’t open. The air really is not safe…. They are not healthy buildings.”

Infection Control Today®: Doctor Kavanagh, you’re writing an article for the October issue of Infection Control Today® about some of the problems involved in trying to reopen schools in the midst of the COVID-19 pandemic. What did you find out?

Kevin Kavanagh, MD: Well, one thing is, is that we really do need to pay attention to the science, and we need to guard our children. That’s probably two of the most important factors. There are too many that think well, we can just open up schools and we don’t need to do much different rather than putting our children in school because they’re very low risk. Well, there’s two factors which I think you need to realize. One is that the children do become infected with the virus almost as frequently as adults and they can spread the virus. They’re just asymptomatic carriers. One study found that approximately 80% of children who are infected with the SARS-CoV-2 virus are asymptomatic. But that does not mean that they cannot spread it to their parents and guardians who are looking after them. And also close to 24% of teachers are at high risk for developing COVID-19. The second factor is that even though children are not at very high risk of dying from COVID-19, they still may develop long-term effects from this virus. And this includes those that are asymptomatic carriers. In children less than age 19, only about 2% are hospitalized. But even those children, in children who are asymptomatic, may be at risk for long-term damage and effects on their heart. It’s not likely to happen, but it certainly can. As you know, we have recent reports out of Penn State that up to 15% of college football players who tested positive for COVID-19—and this includes both symptomatic and asymptomatic patients—has a mild carditis. And this may present many years down the line with a cardiomyopathy. Now you’ll hear people say, “Well, we don’t know what that means. They’re asymptomatic, so they probably won’t develop anything.” Well, the problem with that narrative is, is we just don’t know. And dilated cardiomyopathy, which is the most common type, almost 50% of those are idiopathic, or you do not know what caused them. And it’s felt to be caused by an asymptomatic, viral myocarditis. And so, this is cause for concern. And as you know, children can also rarely develop that Kawasaki-like disease, which can occur in approximately 1% or less of those that develop COVID-19. And that is a severe illness and can be very, very life-threatening.

ICT®: In the article you’re writing for Infection Control Today® for our October print issue, you also write about how school buildings in general aren’t really safe for our children.

Kavanagh: Well, that’s correct. Our schools in many areas are just plain dying, their infrastructure is crumbling. Their windows don’t open. The air really is not safe. Even before COVID-19, it was well known that if your child goes to school, you may well get more colds and also could come down with the flu. They are not healthy buildings. We do need to take this time and upgrade the infrastructure of our schools. This includes bigger classrooms, more hand-washing stations, but also better circulation of air, filtration of air, and cleaning of the air. Look what the airline industry has done for airplanes. They place a number of people inside a small metal tube, but rarely are you hearing about them getting infections. Why? They have excellent circulation of air, excellent cleaning of air, they require everyone to wear masks. And whenever possible they are employing social distancing. The same needs to be done for schools, wearing of masks and social distancing—not and/or—but both. And social distancing needs to be a minimum of six feet. One of the things we’ve learned about this virus is that under certain circumstances, it can aerosolize and this includes loud speech, actively screaming, talking loudly. And in that case, cloth masks and the six-foot rule may not be enough. And this is the reason why you also need a variety of interventions, including upgrading the school’s air systems.

ICT®: I think that the US Centers for Disease Control and Prevention has guidelines for office buildings that are refurbishing in terms of their airflow to make sure they’re safe before they open, is that not the case?

Kavanagh: I believe that is correct. And the same should apply for schools. It really is crucial. We need to pay attention to the infrastructure, we need to learn to live with the virus. Now some will say, well, this epidemic will go away. Well, you know, it really doesn’t matter. Our children are our most precious asset, they should be in a healthy environment. And if it cuts down on the spread of the flu, the spread of colds, of other pathogens, that investment will be well worth it. This is something we really need to do. And we need to open up schools at a time when it is safe to do so. What I mean by that is a community spread of the virus needs to be low and currently we are getting into almost an untenable position where neither alternative is good. Where students stay home, and they will possibly suffer psychological damage and loss of socialization skills. Or if they go to school, it’s too risky. And all of this is a result of society not following public health advice and driving down the community infection rate and our test positivity rate to less than one. And I’m saying less than one. You will hear less than five. But that is a bare minimum, the number five. New York City is having trouble opening up schools, and their test positivity rate is less than one.

ICT®: Who would oversee the refurbishing of schools?

Kavanagh: I would think it would be under the state departments of education. If you go into local governments, it’s going to be really a whack-a-mole approach with different standards everywhere and the virus doesn’t care. It’s not different everywhere. It is the same entity. And strategies that work in one place will work in another and strategies that don’t work in one place won’t work in another. And certainly, it’s going to require grants, either state or federal funding in order to get this infrastructure up to speed. And this will also stimulate the economy. Similar to going to war with an outside adversary, believe me, this virus is the same thing. We need to really invest in infrastructure, not only in schools, but office buildings and restaurants. All of this will require money. I think state grants would be great. And I also think that that’s a way to stimulate our economy, let alone increase the safety of our children.

ICT®: Do infection preventionists fit in this scenario at all with schools and school safety?

Kavanagh: Well, definitely. I think you’ll find that infection preventionists in this type of climate are just not healthcare employed personnel. They need to be everywhere. They need to be in business. They need to be in schools. And, of course, they need to be in our healthcare system. But it is crucial to be in schools, to advise schools on the type of restrooms to have, on the type of social distancing, on how to set up a cafeteria, on how to filter air, on the type of PPE needed. And we do need to get the same quality of PPE for our teachers that is available for healthcare personnel. So yes, we need to look at this as not a healthcare problem, but as a societal problem, and infection preventionists are absolutely key in getting us back on track, both with the economy and getting us to be safe, as safe as we can be when we leave our homes.

This interview has been edited for clarity and length.