Strategies for Infection Control in K-12 Schools

Strategies for Infection Control in K-12 Schools June 11, 2020 | Elevar Design Group Regan Henry, PhD, RA, LEED AP, LSSBB | Lisa Cameron Gulley | Cyndi Klein | Tony Lozier, PE, LEED AP

Strategies for Infection Control in K-12 Schools June 11, 2020 | Elevar Design Group Regan Henry, PhD, RA, LEED AP, LSSBB | Lisa Cameron Gulley | Cyndi Klein | Tony Lozier, PE, LEED AP

Schools play many important roles within our communities by teaching, nurturing, and feeding our young people. As community centered facilities, schools may also play an important role in slowing the spread of contagious diseases. With the Department of Education considering next steps in the COVID-19 crisis response, many districts are seeking guidance on how to provide a safe and healthy learning and working environment for both students and staff.

While information about COVID-19 in children is limited, research suggests infected children generally have mild symptoms or are asymptomatic.1 Children carrying the virus may play a role in spreading disease through communities via person-to-person contact, but new research suggests pediatric transmission is less than was initially feared.3 Because children express the disease mildly or not at all, they are less likely to sneeze or cough, decreasing transmission rates.3 Taking precautions to ensure the well-being of both students and staff is vital to any ‘back to school’ planning. Evidence shows that older adults and people with serious underlying medical conditions are at highest risk of severe illness from COVID-19. Considering that 30.7 percent of teachers in the United States are over 50 years of age4, 27.1 percent of principals are over 55 years of age5, and the mean age of superintendents is between 54 and 55 years of age6, many staff members are at high risk for severe illness when infected (see Figure 1).

What is COVID-19?

“Coronavirus” is a generic term describing a large family of viruses. COVID-19 is the disease caused by the virus SARSCoV-2, or Severe acute respiratory syndrome coronavirus 2.

SARS-CoV-2 is a betacoronavirus, like MERS-CoV and SARS-CoV. Betacoronavirus are enveloped, positive-sense, single-stranded RNA viruses of zoonotic, transmissible to humans from animals, origin.7 COVID-19 is nearly twice as contagious as the typical flu with a reproductive ratio (R0) greater than 2. When a R0 is between 0 and 1, a virus is prevented from spreading and the disease will die out in a population. When a R0 is greater than 1, the disease will spread.8 The threat of COVID-19 will be present in our communities until (1) a vaccine is developed or (2) the R0 drops below 1 due to preventative measures such as isolation and quarantine or reaching a point of herd immunity; Neither solution will happen quickly.9 The COVID-19 virus, SARS-CoV-2, is measured between 60 to 140 nm and averaged to 125nm or 0.125 Microns for discussion.

The virus often travels in larger vacuoles of biological aerosols – transmitted through coughing and sneezing - which range in size from 0.5-3 Microns.

How is it Transmitted?

We are still learning more about how the SARS-CoV-2 virus spreads. The two main methodologies for infection are thought to be (1) person to person or (2) transferred via an intermediate surface. A study published in The New England Journal of Medicine shows that the virus is present in droplets for up to three hours after being coughed out into the air and can remain airborne for several hours in still air.10

2

Strategies for Infection Control in K-12 Schools June 11, 2020

Average Age of Public School Officials in the US Percentage of Teachers 15.3% >30 yrs

Percentage of Principals

18.8% 55+ yrs

33.1% 45-54 yrs

11.9% 50-54 yrs

54.0% 30-49 yrs

27.1% 55+ yrs

39.7% >45 yrs

Average Ages of Teachers: 42.4 years

Average Age of Principals: 48 years Figure 1

The current consensus is that the virus is spread predominantly via person to person large droplet transfer. This means droplets too large to remain airborne are spread through speaking, coughing, or sneezing within a close range of other people.

The Center for Disease Control (CDC) puts this range at about six feet – hence the social distancing requirement of six feet separation.11

Below are some strategies for infection control that may be implemented in an educational setting.

Strategies for Infection Control Policy Follow CDC Guidelines

The Center for Disease Control (CDC) website has a cache of information on policies and procedures to address the COVID-19 pandemic in schools. The CDC has published directives based upon three tiers of risk tolerance. In Figure 2, excerpts of the guidelines are provided to illustrate the need for measured district reaction.

Social Distancing

The U.S. government has mandated that all people should keep six feet of social distance, limit or cancel larger gatherings, and stay at home and isolate one’s self if showing symptoms of the disease. While maintaining social distance plays a large part in the battle against the spread of the virus, we know the virus can last in the air and on surfaces long after an infected person has moved on. Social distancing is best performed in separate and isolated zones – promoting working from home or a dedicated space that has a six-foot clear radius. All shared tables, common areas, and meeting rooms require thorough sterilization between use.

Stay Home

Staying home remains the safest option for most. A survey from the National Foundation for Educational Research found that when Parents in the United Kingdom were given the choice to return to school: 46% of parents will keep children at home; 50% of parents in schools in disadvantaged areas will keep children at home; and 25% of teachers are likely to be absent because of health issues for themselves or their families.13 Until a vaccine is identified or herd immunity achieved, students and staff able to work from home are safest staying home – especially those who may have preexisting conditions or comorbidities. The district should work with the community and employees to identify which persons are ‘high-risk’ and coordinate alternate work or study programs for ELAthem – see Infectious Disease Preparedness and Response241 Plan.14

CDC: Guiding Principles to Keep in Mind The more people a student or staff member interacts with, and the longer that interaction, the higher the risk of COVID-19 spread. The risk of COVID-19 spread increases in school settings as follows: Lowest Risk: Students and teachers engage in virtual-only classes, activities, and events.

More Risk: Small, in-person classes, activities, and events. Groups of students stay together and with the same teacher throughout/across school days and groups do not mix. Students remain at least 6 feet apart and do not share objects (e.g., hybrid virtual and in-person class structures, or staggered/rotated scheduling to accommodate smaller class sizes).

Highest Risk: Full sized, in-person classes, activities, and events. Students are not spaced apart, share classroom materials or supplies, and mix between classes and activities.

COVID-19 is mostly spread by respiratory droplets released when people talk, cough, or sneeze. It is thought that the virus may spread to hands from a contaminated surface and then to the nose or mouth, causing infection. Therefore, personal prevention practices (such as handwashing, staying home when sick) and environmental cleaning and disinfection are important principles that are covered in this document. Fortunately, there 1C are a number of actions school administrators can take to help lower the risk of COVID-19 exposure and spread during school sessions and activities. 12 Figure 2

Classroom De-Densification

While schools may officially open in the Fall of 2020, many families will not be comfortable sending children back into the traditional academic environment. Districts are encouraged to create alternative study plans to allow families to choose remote learning. While implementation will require nuance and accountability, providing flexibility to accommodate varying levels of comfort through blended learning (classroom, online, and mobile platform learning) is the goal.

De-densification

To enforce social distancing, the denominator for the maximum space occupancy calculation must be adjusted. A suggested six-foot radius per individual results in a maximum density of 1 person/30 Usable Square Feet. As an example, a traditional 810 square foot classroom that once sat 25 students may now only be large enough to seat 13-15 in order to maintain appropriate clearance (Diagram 1: Classroom De-densification).

Diagram 1

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

3

Strategies for Infection Control: Policy

Circulation and use in lobbies, conference rooms, and common spaces should be carefully choreographed and monitored. This may be as subtle as demarcating distances with colorful tape on the floor or a plexiglass screen positioned around a reception desk. All shared surfaces require thorough sterilization between use.

Upon return to school, consider devoting a portion of the curriculum to teaching students about the disease and preventative steps to mitigate exposure. This training will look very different from elementary to high school.

Social Distancing

Stay Home

De-Densification

Split Shift Learning

Temperature Checks

Preparedness & Response Plan

Classify Exposure

Choreograph Circulation

PPE

Prepare signage to post throughout the building to communicate and remind building users of the policies and their importance at containing the spread of disease.

Split Shift Learning

Explore creating ‘shifts of learning’ to minimize the number of exposures. Consider allocating students to certain days of week or hours of the day. Sanitize following each transition to prevent cross contamination between shifts. This technique may be paired with a blended learning strategy to make lessons available both in person and virtually. The State Department of Education has the option and may choose to expand the length of school year to accommodate for shift utilization and dedensification of facilities.

Temperature Checks

Thermal scanners are effective in detecting people who have developed a fever - a central symptom of COVID-19 infection.15 Identifying and quarantining those presenting with an elevated temperature is a productive way to prevent the spread of disease – COVID-19 or other illnesses. However, because it takes between two and ten days before people who are infected with COVID-19 to develop a fever, this preventative method still allows for transmission of the disease within the ten-day window.16 Ideally, temperature checks are performed directly before or immediately after entry. Because testing every student may be unrealistic, consider choreographing entry points and arrival times for students to stagger the flow or perform random testing to enforce stay at home messaging for those who may be ill.

Once COVID-19 instant tests are more widely available, these checkpoints may act as testing centers for workers and visitors, a factor to consider when planning and installing a station.

Infectious Disease Preparedness and Response Plan Support Whole Child Health

Rethink Curriculum

Flex Grade Levels

The Occupational Safety and Health Administration (OSHA) recommends that an Infectious Disease Preparedness and Response Plan be developed to understand key risk factors that may make staff more sensitive to infection (e.g., over 65 in age; presence of chronic medical conditions, immunocompromising conditions; pregnancy) and put measures into place to protect the health of these high-risk individuals.17

Alternative remote education or roles for high-risk students and staff with underlying immunodeficiencies, diabetes, asthma, etc. should be planned. 18

Limit Visitors & Events

4

Intoduce Contact Tracing Apps

Strategies for Infection Control in K-12 Schools June 11, 2020

Classify Exposure

Another planning tool designed by OSHA divides job tasks into four risk exposure levels: ‘very high, high, medium, and low’ risk. ‘Very high’ and ‘high’ are associated with roles in healthcare – nurses, physicians, morgue workers – as they treat infected patients. The traditional teacher

falls into the ‘medium’ risk category. However, because the amount of exposure to COVID-19 correlates with increased virulence, some office workers with public facing roles (i.e. busy receptionist or school nurse) may rise to the level of ‘high’ and warrant additional precautionary protective measures, including enhanced personal protection equipment or temporary physical barriers.19

Choreograph Circulation

In an effort to minimize the number of shared spaces and de-densify funnel points, new circulation plans and schedules should be planned for students and staff. Different grades or ‘homerooms’ may be assigned separate entrances, stairwells, and bathrooms to minimize cross contamination of people and surfaces. Just as our groceries have planned morning hours for senior citizens, a school may have assigned waves of arrival and departure times for students and staff to stagger building utilization.20 Consider adding signage or lines of colorful tape on the floor to indicate planned patterns movement.

Personal Protection Equipment

While face coverings are not recommended for children under age two (because of choking or strangulation hazard) face coverings are recommended for children over two and adults.21

While traditionally students moved through crowded hallways to get to classes, consider minimizing students’ movement and contact by having teachers circulate through the building. This may require detailed coordination of both student and teachers’ schedules and the possible launch of an in-school remote learning platform.

Assignments requiring collaboration or small groups should be managed in a way that encourages safe distance or virtual connection.

Flex Grade Levels

Consider adjusting cycles of learning bound by factors other than age. Assuming a certain order of magnitude within the student population, grouping students by proficiency rather than age allows for a more tailored curriculum. When students are learning around the same level, less one on one or small group tutoring is required.

Ohio guidelines for childcare centers required children from the same family be assigned the same room, regardless of age.

Districts may consider how a similar policy could work in a K-12 setting. Depending upon age disparity, multi-age learning may utilize blended learning delivery with emphasis on the teacher acting as facilitator of a prepared curriculum rather than subject matter expert.

Personal protection equipment (PPE) ranges in sophistication with the most protective material saved for front line healthcare workers – or those in the OSHA ‘high’ and ‘very high’-risk categories. For the traditional school administrator or teacher of ‘medium’ risk, the CDC recommends the use of cloth face coverings to both slow the spread of the virus and help asymptomatic or pre-symptomatic people from unknowingly transmitting it to others. Many states have adopted the recommended use of cloth face coverings into their COVID-19 response mandates. Students and staff should be expected to use face coverings. These materials should be provided by the district to ease the burden of expectation. However, with strained supply chains, creative solutions for sourcing masks may be necessary.22

Limit Visitors and Events

For employees identified as ‘at-risk’ during development of the OSHA Infectious Disease Preparedness and Response Plan or for staff in the OSHA Risk Exposure Levels of ‘very high’ or ‘high’, PPE requirements will be more stringent. For these groups, districts are to refer to the CDC guidelines for higher risk employees.

New technologies are being created and adapted to track individuals’ movement and record instances of sustained (+10 minutes) contact. This contact tracing technology provides smart data to public health officials to identify locations where COVID-19 may have been transmitted, expediting, and improving contact tracing efforts. Users will also be notified if exposed to a COVID-19 positive person.23

Support Whole Child Health

The long-term effects of social distancing on social development are unknown. While significant effort is going into adapting curriculum around virtual learning, energy must also be spent to protect the social and mental health of our children. The economic fallout has destabilized many families. Because the school community has traditionally been the liaison between families and social services, it is important that districts work to build and bolster a system of support to respond to the many changes facing our communities. This may require schools to foster social bonds and community through new programs and outreach initiatives. Schools are encouraged to communicate directly with families to identify and understand the evolving needs of the students.

Rethink Curriculum

Teachers and administrators may wish to connect on ways to enforce safety and distance protocols within daily activities and assignments. Sharing tools or equipment – desks, computers, chairs, rugs – is discouraged.

Because of the added risk and liability, visitors to a school should be limited. It is recommended to transition to digital forms and communication whenever possible to limit in-person visitors. The use of schools for alternative programming after hours - night or weekends- should be evaluated and protocols for use clearly established.

When community outbreak is a threat, non-essential activities, events, and meetings should be hosted remotely or cancelled.

Prepare a plan with additional safety measures and precautions for required deliveries to the school.

Introduce Contact Tracing Apps

Districts may wish to utilize or encourage utilization of such applications on school and / or personal devices. To combat user concerns regarding location tracking privacy, the Massachusetts Institute of Technology (MIT) based makers of ‘Safe Paths’ have developed a free, open-source, platform with privacy options aimed at flattening the curve of COVID-19, reducing fear, and preventing a surveillance-state response to the pandemic.

Continuity of Learning Plan in Place

How COVID-19 will influence our future and for how long is unknown. Many public health statistical models show a second wave of disease impacting our communities as early as the Fall of 202024. It is important for districts to have plans in place to implement a pivot to virtual learning quickly and with minimal challenges. This may include investing in computers for all students, establishing web-based learning platforms, adapting curriculum for the home environment, upgrading community WIFI, and/or polling families to better understand potential hurdles to students’ success.

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

5

Place New Classroom Configurations

Assigned spaces of 6’ clearance around each child is encouraged. This may look like colored tape on the floor to demarcate boundaries or carpet tile color changes. Personal property should be contained within this bubble. Lockers should only be used if necessary and use scheduled to prevent forced contact with others.

Minimizing the intermingling of students is important to controlling the spread of a potential outbreak. Whenever possible, students should be grouped into ‘homerooms’ and limit their interaction with other ‘homeroom’ groups.

‘Homeroom’ groups cycle in, out and through the building together, disinfecting shared surfaces or touch points before and after use.

Encourage Outdoor Learning

Research shows the chances of infection are directly correlated to the amount and time spent exposed. Being outside and breathing fresh air significantly minimizes transmission of disease. A study of 318 outbreak clusters of COVID-19 in China suggests that most of the outbreaks were associated with indoor

Strategies for Infection Control: Place

air transmission, while outdoor transmission was rare.25 A transition to more outdoor learning may be encouraged by setting up outdoor classrooms and study environments.

Teachers may choose to incorporate outdoor learning into their curriculum planning. Depending on site and climate conditions, equipment such as stools, mats, or portable heaters may assist with student and staff comfort.

More and Better Technology

As the methods of learning and teaching evolve, the technology must also adapt. If remote learning is to remain an option for students, districts may consider installing 360-degree cameras and audio in each classroom. Such integrative hardware would allow for teachers to livestream lessons to remote learners.

Depending upon the age and sophistication of existing microphone systems, many schools may already have the audio requirements within their school infrastructure.

Clinics Throughout

The school clinic has served a vital role to many students prior to the pandemic. The school nurse is traditionally responsible for distributing medications, testing blood sugars, and performing temperature checks. Today the school clinic will have the added responsibility to identify those suspected of COVID-19 infection. Districts may consider setting up two clinic spaces within a school: one for normal day-to-day functions and a second for those suspected of infection. The latter should be located with direct access to the outside to limit potential for infection through circulating through the school.

As an added precaution, teachers may also be given thermometers to enact discretionary temperature checks and/or trained to recognize common signs and symptoms of the disease.

Safeguard Administration

New Classroom Configurations

Outdoor Learning

More and Better Technology

As with limiting visitors into the school, districts may also choose to limit circulation in and out of certain areas. Minimizing movement and exposure to different areas in a building helps keep infectious diseases from spreading. Consider hosting remote administrative meetings, enact digital forms and evaluations, set up virtual ‘office hours’ for key administrators to be available to parents and staff with questions or concerns.

Individualize Gym and Recess

Clinics Throughout

Safeguard Administration

Individualize Gym & Recess

Limiting touch points is important to controlling transmission of the virus. Because the virus may live on surfaces for hours, administrators may opt to close outdoor play structures and equipment.26 Gym and recess time will need to be reprogrammed to include activities that preserve social distancing requirements and avoid the shared use of equipment such as a ball or mat.

Several recess locations may be planned across the campus to preserve homeroom populations and prevent intermingling of classes, students, and teachers.

Safe Food Service Safe Food Services Service

6

Repurpose Common Areas

Minimize Bussing

Strategies for Infection Control in K-12 Schools June 11, 2020

Consider cafeteria workers delivering bagged lunches to each classroom and having students eat lunch in their homeroom classes. All food preparation should follow CDC guidelines.

Districts may consider using disposable food service items (e.g., utensils, dishes).

If disposable items are not feasible or desirable, all reusable items should be handled with gloves and sterilized with dish soap and hot water or in a dishwasher.27

Strategies for Infection Control: Operations & Maintenance

Repurpose Common Areas

As social distancing requirements decrease the number of students allowed in each classroom and gatherings of more than ten people are discouraged, consider repurposing common areas (gym or cafeteria) for social distanced learning.

Districts may invest in temporary, sound deafening, non-porous partitions to divide larger spaces into learning ‘rooms’. With the appropriate technology and oversight, students may connect virtually with their classroom despite being physically separated.

Other accommodating features to consider with this type of retrofit are flexible furnishings, mobile partitions, audio/visual technology, and smart white boards.

Minimize Bussing

Enhance Custodial Decommission Equipment Services

Hand Sanitation

Prepare a bussing plan to accommodate for additional safety precautions for both students and driver. Encourage families to drive students whenever possible and coordinate drop off and pick up patterns to minimize forced contact or cross contamination.

If bussing is continued, have clear protocols for seating assignments, space occupants every other row to maintain social distancing, and establish expectations for circulation to limit close passing or congregation in the aisle.28

Operations & Maintenance Enhance Custodial Services

The Center for Disease Control (CDC) has issued clear directives for effective cleaning methods and products, enhanced frequency of cleaning throughout the workday, and focused sterilization overnight.

New cleaning operations may include: • Provide cleaning supplies and cleaning protocols for all staff and older students • Clean and disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, handrails, and doorknobs regularly • Adopt electrostatic spraying technology to more thoroughly disinfect surfaces • Remove or prevent the use of fabric, porous, or hard to clean surfaces • Provide tissues and no-touch trash receptacles for all staff and students – empty and clean receptacles often These enhanced cleaning protocols require increased staff, more exacting supplies, and enhanced equipment.

One sterilization technique that has profound impact involves UVC or germicidal light emitting systems. Today, UVC-emitting

Decommission Jet Air Dryers

Minimize Touch Points

Timed Handwashing

Consider Copper

Physical Barriers

robots are cleaning floors in hospitals and operating rooms, while banks use the powerful germicidal light to disinfect money.

Handheld UVC light emitting equipment is commercially available for spot disinfection. Enhanced cleaning equipment such as UV-C emitting systems or electrostatic spraying technology may be a worthwhile investment in high-risk environments.

Disinfect student-used equipment and materials after every use. Student cubbies in younger grades are typically open, therefore easy to disinfect. Lockers for older students may need to be decommissioned or retrofit to allow for more productive cleaning.

Decommission Playground Structures and Other Shared Equipment

When possible, decommission equipment that will be ‘highrisk’ for contamination. Knowing a virus may live on a surface for hours unless disinfected, shared playground structures, recreation equipment, or computer hardware may be an agency for disease. A challenge for staff is to explore what socially distance ‘play’ looks like and how it may be monitored, especially with younger students.

Minimize Touch Points

While many modern restrooms have motion sensor fixtures, today the importance of eliminating shared touch points is paramount. Consider removing unnecessary high-risk touch points and installing products designed to minimize cross contamination of users.

• Remove unnecessary doors where possible to have barrierless transitions between rooms • Retrofit fixtures (i.e. lights, toilets, faucets, soap/sanitizer dispensers, drinking fountains) to be motion sensor or foot enabled • Install automated door opening hardware where reasonable

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

7

Strategies for Infection Control: Engineering Controls

launch moisture, including viral droplets, back at the hand and into the surrounding air, contaminating the hands and air in the restroom for anyone nearby.32 Removing or decommissioning jet air drying in bathrooms and installing paper towel dispensers is recommended during the pandemic.

Consider Copper

Increase Outside Air

Increase Air Exchange Rates

Ionized Cleaning

Viruses, bacteria, and yeast cannot survive for long periods of time on metallic copper surfaces. Districts may choose to retrofit high touch surfaces like doorknobs or push plates with copper hardware to help control the spread of disease. However, because the contact killing time for viruses on copper falls between 45 and 180 minutes, the use of copper must also be used along with other methods of disinfection and hygiene protocols.33

Install Physical Barriers

UV-C Light

HEPA Filters

50-60% Relative Humidity

• StepNPull adaptations to doors to enable opening a door with a shoe instead of hand • Reverse door swings or retrofit doors with multi-directional swing hinges • Install hold open hardware to keep required doors in an open position unless triggered by alarm While not all touch points are avoidable, the dangers may be mitigated by paying careful attention to common circulation patterns and addressing high risk surfaces with regular and thorough cleaning protocols.

Encourage Timed Handwashing

Print and post copies of the CDC’s, “Life is Better with Clean Hands” posters to raise awareness and accountability for routine handwashing.29 Post the CDC’s guidelines for handwashing above the faucet on the restroom mirror next to a passage or song that takes 20 seconds to read or sing.30 When expectations are clearly outlined and visible they are harder to ignore.

Provide Hand Sanitation Centers

Install hand sanitation centers at high frequency locations and high-risk touch points. The hand sanitizer should be at least 60% alcohol and applied per CDC guidelines: covering all surfaces and rubbed in until hands feel dry (approximately 20 seconds).

Begin a public health campaign by posting guidelines and promotional materials to encourage frequent and effective use of hand sanitizer throughout the school.31

Decommission Jet Air Dryers

A study presented in the Journal of Applied Microbiology addressed the efficacy of hand drying with paper towels versus jet air or warm air drying. The findings were conclusive: jet air drying resulted in significantly more viral contamination. The average number of virus particles scattered by the jet air dryer were 2219; warm air dryer, 34; and paper towel, 2. Jet air dryers

8

Strategies for Infection Control in K-12 Schools June 11, 2020

At high frequency locations, such as a reception desk or nurses office, installing clear plastic surrounds may be appropriate to protect both parties against contamination. Where face to face interaction is required and social distance requirements unachievable these dividers are critical to protecting public facing employees. Just as a sneeze guard at the buffet protects the food from contamination, a plexiglass divider will prohibit contagions from crossing into ones’ personal space.

Engineering Controls Design and install engineering controls to reduce or eliminate exposure within the school building. Examples of engineering controls include:

Increase Outside Air

As we learned in science class, “the solution to pollution is dilution,” buildings that achieve higher ventilation rates will reduce risk. The more fresh air that comes into a space, the less likely stale and infected air is able to settle. Whenever possible Heating, Ventilation and Air Conditioning (HVAC) systems should be modified to increased fresh air delivery – the more the better.

While bringing in new air may test the limits of a heating and air conditioning system, the optimum balance is to provide a maximum volume of fresh air while maintaining the ability of a HVAC system to keep a comfortable temperature.

Whenever possible, opening operable windows (and encouraging circulation with fans) to refresh inside air is encouraged. The World Health Organization (WHO) has established guidelines for how to appropriately naturally ventilate in healthcare facilities - a useful resource should this strategy be possible in a school.34

Increase Air Exchange Rates

The COVID-19 virus will circulate in unfiltered air conditioning systems for several hours; however, aerosol droplets tend to settle on surfaces faster in disturbed air.35 In addition to increased outside air, research suggests increasing the air exchange rates helps circulate air and move dangerous microbes. Outside air intake must be increased at the Air Handling Unit (AHU) and in the system by which air is distributed throughout the space.

Many Variable Air Volume (VAVs) HVAC systems operate at 60% of capacity. Adjusting the system to operate closer to 80% of capacity allows for greater replacement and circulation of air in a given time period. The ability to retrofit existing systems is dependent upon the existing equipment and programming capabilities.

Ionized Cleaning

Several new technologies focus on sterilization by means of molecular binding. Ionized cleaning equipment releases thousands of oxygen ions per cubic centimeter of air. These super-charged ions bind to molecules – viruses, bacteria, fungi and mold - agglomerating into larger particulates and destabilizing the microbe. Routine ionization of indoor air is shown to substantially minimize chance for infection.36 Ionized molecules are proven to kill viruses, bacteria, fungi, and mold not only in the air but also on surfaces such as counter tops, light switches, phones, and doorknobs, preventing cross contamination. Third party tests have demonstrated bi-polar ionization has a significant reduction rate on a SARS-CoV-2 surface strain. In laboratory tests after 10 minutes of exposure to bi-polar ionization 84.2% of the SARS-CoV-2 viral particles became inactive, at 15 minutes 92.6% of the viral particles became inactive, and at 30 minutes 99.4% of the viral particles became inactive.37,38 Ionization equipment can either be installed into an existing facility’s HVAC system (both AHU or VRF) to sterilize circulating air or as an independent unit (wall mounted or portable) to disinfect a room in less than an hour.39 Different proprietary equipment have options to interface with an existing building management system to provide full control and measurable performance.

UV-C Light

UV-C or germicidal light is a technology being used to sterilize hospital operating rooms, planes, and subway trains. These shorter, stronger light waves can penetrate deep into the microbe destroying genetic material - sterilizing the air and surfaces exposed to the light.

Ultraviolet light can be retrofit into an existing AHU. This initial expense is minimal, yet it provides the following benefit:

Commonly used in critical care environments within healthcare facilities, HEPA filters are 99.97 percent effective at trapping particles down to 0.3 microns in size. Thus, HEPA filters can capture SARS-CoV-2 contained within the aerosol particles, which last longer – but not SARS-CoV-2 microbes themselves. Even HEPA filters that have been tested in the laboratory with viruses have some level of virus penetration.

The addition of a HEPA filtration will cause an increase in static pressure in a system otherwise not designed for it.

Additional static pressure can significantly increase fan energy requirements, causing a dramatic decrease the air exchange rates and decreased fresh air into the space - a tradeoff that must be measured on a case by case basis. HEPA filters are effective when designed as an original element of an HVAC system, but difficult to add to an existing HVAC system.

When carefully selected and designed, single-space highefficiency filtration units (ceiling mounted or portable) may be highly effective in decreasing concentrations of infectious aerosols in a classroom space.41

Maintaining 45-60% Relative Humidity

Relative Humidity (RH) is shown to affect the viability of a virus in aerosols by controlling the amount of water retained, the size of an aerosol, the concentrations of solutes, and its pH.42 Viruses that require acidification before fusion, such as SARSCoV-2, are less stable at 50 to 90% RH than at RHs outside this range. However, droplets containing the virus can live longer on surfaces in high humidity conditions. Traditional viruses are least viable in that range of 40 and 60 percent RH. When RH levels fall below 35 percent viruses thrive in the body because the respiratory system is less able to clear infection.43 Research suggests a target of 45% to 60% indoor RH is ideal for destabilizing the COVID-19 virus and maintaining a healthy immune response in employees.

Operating and installing humidifiers in an AHU is expensive.

Humidifier distribution systems need a lot of distance on their inlet and outlet, for putting moisture into the air and the moisture being absorbed by the air before any obstruction forced the water droplets out of the air. The value of such a system retrofit would need to be evaluated on a case by case basis.

• Ensures sterilized air is circulating through the system • Lower cases of airborne illnesses – healthier building occupants • UV-C light kills microbials growing on coils or within ducts – improving the output volume • Cleaner systems equate to decreased energy required for AHU performance and lowered costs • Lower maintenance costs due to cleaner coils and ducts40

Smaller humidifiers designed to titrate humidity levels in a single room may be a solution for achieving the desired threshold for relative humidity in classrooms. Either portable, standalone equipment or wall mounted equipment may be useful to integrate into a facility operations strategy.

The World Health Organization cautions that while this technology will kill a virus, it does not discriminate between good and bad cells and has deleterious health consequences on our bodies (especially eyes) in seconds of exposure. For this reason, only highly trained personnel should work with this type of product. Because of its revolutionizing sterilization ability, UV-C light systems and installers are in very high demand globally.

Our understanding of the coronavirus and its impact in our communities is constantly evolving. This paper is written to instigate a dialogue amongst district administrators to examine, on a case by case basis, which of the above strategies may be adopted into a re-opening plan.

This technology may be used in conjunction with other strategies as part of a larger plan to sterilize circulating air.

HEPA Filters

The most sophisticated High Efficiency Particulate Arrestance (HEPA) filters capture microbes, dust, and particulates.

Conclusion

Researchers, the WHO, and the CDC are working on gathering additional information to help schools determine when and how to re-open in a safe and orderly manner.44,45,46 Districts should work together with local health officials to understand the magnitude of their community’s exposure and plan accordingly.

Districts should check in regularly with both local and state health departments, as well as the Department of Education on evolving policies and implications of local epidemiological models.

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

9

Regan Henry, PhD, RA, LEED AP, LSSB

Lisa Cameron Gulley

Cyndi Klein

Tony Lozier PE, LEED AP

About the Author Regan Henry Architect - Evidence-Based Design/Research

Dr. Regan Henry brings a unique perspective to design through her background as an architect, researcher, and professor. In her role as Senior Architect – Evidence Based Design / Research at Elevar Design Group, Dr. Henry works to adapt the scientific process and evidence-based solutions to modern design problems. She is a Registered Architect, Doctor of Medicine in Molecular Biology (Germany), LEED Accredited Professional, and Lean Six Sigma Black Belt.

Contributing Experts

Lisa Cameron Gulley Senior Designer - Educational Planning

Lisa Cameron Gulley has 20 years of experience in educational programming and design. She has been involved in nearly every educational project Elevar Design Group has completed since 2000. Her knowledge of public and private education design allows Lisa to bring creative and unique solutions to each facility.

10

Strategies for Infection Control in K-12 Schools June 11, 2020

Cyndi Klein Senior Interior Designer

Ms. Klein has more than 30 years of experience as an interior designer, specializing in analytical and research laboratories, offices and support facilities along with other public facilities design. She is responsible for overall interior design management and project coordination, including interior programming and design.

Tony Lozier Senior Vice President - Engineering

Tony Lozier has more than 45 years of experience in MEP Engineering. As the leader of the Engineering team at Elevar Design Group, he directs all engineering services and ensures the highest quality results for clients.

Notes 1 Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics 2020:e20200702. doi:10.1542/peds.2020-0702 2 Don’t Forget the Bubbles, “COVID-19 EVIDENCE REVIEW,” April 22, 2020. https://dontforgetthebubbles.com/wp-content/ uploads/2020/04/COVID-data-top-10.pdf 3 Gudbjartsson DF, Helgason A, Jonsson H, Magnusson OT, Melsted P, Norddahl GL, et al. “Spread of SARS-CoV-2 in the Icelandic Population”. N Engl J Med, Published April 14th 2020, doi:10.1056/NEJMoa2006100.

4 U.S. Department of Education, National Center for Education Statistics, Schools and Staffing Survey (SASS), "Public School Teacher Data File," 2011–12. https://nces.ed.gov/surveys/sass/tables/sass1112_2013314_t1s_002.asp 5 U.S. Department of Education, National Center for Education Statistics, Schools and Staffing Survey (SASS), "Public School Principal Data File," 2011–12.

6 The American Association of School Administrators, “American School Superintendent: 2010 Decennial Study,” December 8,2010 7 World Health Organization (2020), “Naming the coronavirus disease (COVID-19) and the virus that causes it,” 2020, https://www. who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virusthat-causes-it 8 Ana Sandoiu, “Coronavirus may spread faster than WHO estimate,” Medical News Today, February 18, 2020, https://www. medicalnewstoday.com/articles/coronavirus-may-spread-faster-than-who-estimate.html 9 Joseph Eisenberg, “R0: How scientists quantify the intensity of an outbreak like coronavirus and predict the pandemic’s spread,” The Conversation, February 5, 2020, Updated March 27, 2020, https://theconversation.com/r0-how-scientists-quantify-the-intensity-of-anoutbreak-like-coronavirus-and-predict-the-pandemics-spread-130777 10 Dr. van Doremalen, Mr. Bushmaker, Mr. Morris, et.al., “Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1,” New England Journal of Medicine 382 (March 2020):1564-1567. DOI: 10.1056/NEJMc2004973 11 Maria Taylor, “Coronavirus Prompts Response in HVAC Industry,” The News, March 9,2020, https://www.achrnews.com/ articles/142808-coronavirus-prompts-response-in-hvac-industry.html 12 Centers for Disease Control and Prevention, Considerations for Schools, May 19,2020. https://www.cdc.gov/coronavirus/2019ncov/community/schools-childcare/schools.html 13 Caroline Sharp, David Sims, Simon Rutt, “Return of pupils to school: Schools’ responses to Covid-19,” National Foundation for Educational Research, June 1,2020.

14 Owl Labs, “State of Remote Work,” 2019, https://www.owllabs.com/state-of-remote-work/2019.pdf 15 World Health Organization (2020), “Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19),” 16-24 February 2020, https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf 16 World Health Organization (2020), “Coronavirus disease (COVID-19) advice for the public: Myth busters,” https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters.html 17 U.S. Department of Labor Occupational Safety and Health Administration, “Guidance on Preparing Workplaces for COVID-19,” OSHA 3990-03, 2020, https://www.osha.gov/Publications/OSHA3990.pdf 18 Centers for Disease Control and Prevention, People Who Need to Take Extra Precautions April 29, 2020 https://www.cdc.gov/ coronavirus/2019-ncov/need-extra-precautions/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019ncov%2Fspecific-groups%2Findex.html 19 Siddhartha Mukherjee, “How Does the Coronavirus Behave Inside a Patient?” The New Yorker, March 26, 2020, https://www. newyorker.com/magazine/2020/04/06/how-does-the-coronavirus-behave-inside-a-patient 20 Cushman & Wakefield, 6 Feet Office, 2020, https://www.cushmanwakefield.com/en/netherlands/six-feet-office 21 American Academy of Pediatrics, “Cloth Face Coverings for Children During COVID-19”, 4/20/20 https://www.healthychildren.org/ English/health-issues/conditions/chest-lungs/Pages/Cloth-Face-Coverings-for-Children-During-COVID-19.aspx 22 Centers for Disease Control and Prevention, “Coronavirus Disease: Situation Summary,” April 19, 2020, https://www.cdc.gov/ coronavirus/2019-ncov/cases-updates/summary.html

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

11

23 https://covidsafepaths.org/about/ 24 https://www.washingtonpost.com/health/2020/04/21/coronavirus-secondwave-cdcdirector/ 25 https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1; doi.org/10.1101/2020.04.04.20053058 26 American Academy of Pediatrics Council on Early Childhood Reducing the Spread of Illness in Child Care 11/21/2018, https://www. healthychildren.org/English/health-issues/conditions/prevention/Pages/Prevention-In-Child-Care-or-School.aspx 27 Centers for Disease Control and Prevention, Considerations for Schools- Maintaining Healthy Environments, May 19,2020. https:// www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html 28 Centers for Disease Control and Prevention, What Bus Transit Operators Need to Know About COVID-19 , 4.14.2020, https://www. cdc.gov/coronavirus/2019-ncov/community/organizations/bus-transit-operator.html 29 Centers for Disease Control and Prevention, “Life is Better with Clean Hands,” April 13, 2020, https://www.cdc.gov/handwashing/ campaign.html 30 Centers for Disease Control and Prevention, “When and How to Wash Your Hands,” April 2, 2020, https://www.cdc.gov/ handwashing/when-how-handwashing.html 31 Centers for Disease Control and Prevention, “Hand Sanitizer Use Out and About” April 13, 2020, https://www.cdc.gov/ handwashing/hand-sanitizer-use.html 32 Kimmitt, P.T. & Redway, K.F. (2016). Evolution of the potential for virus dispersal during hand drying: a comparison of three methods. Journal of Applied Microbiology. 120,478-486 33 Grass G., Rensing C., and Solioz M., “Metallic Copper as an Antimicrobial Surface.” Applied and Environmental Microbiology, Mar. 2011, p. 1541–1547 Vol. 77, No. 5 doi:10.1128/AEM.02766-10 34 Atkinson J., Y. Chartier, C.L. Pessoa-Silva, P. Jensen, and W.H. Seto. 2009. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization. www.who.int/water_sanitation_health/publications/natural_ventilation/en.

35 Richard Gray, “Covid-19: How long does the coronavirus last on surfaces?” March 17,2020, https://www.bbc.com/future/ article/20200317-covid-19-how-long-does-the-coronavirus-last-on-surfaces 36 http://www.activeairsolutions.biz/AAS%20Schools%202-pager%20final.pdf 37 GPS and Innovative BioAnalysis, “Independent Laboartoy Test Results,” June 2020. https://files.constantcontact. com/7a66ea4d401/669e78c0-ddf4-4688-80f5-53fa032aed23.pdf 38 Sergeya, et. al., “Control Of Aerosol Contaminants In Indoor Air: Combining The Particle Concentration Reduction With Microbial Inactivation.” Center For Health-Related Aerosol Studies, Department Of Environmental Health, University Of Cincinnati 39 https://www.plasma-air.com/application/165 40 Firouz Keikavoisi, “UVC: Florida Hospital Puts HVAC Maintenance Under A New Light,” Engineering Systems Magazine, February 24, 2004, 1245 41 American Society of Heating and Air-Conditioning Engineers (ASHRAE), “Position Document on Infectious Aerosols,” April 14, 2020, https://www.ashrae.org/file%20library/about/position%20documents/pd_infectiousaerosols_2020.pdf 42 Yang W, Marr LC. “Mechanisms by which ambient humidity may affect viruses in aerosols,” Appl Environ Microbiol.

2012;78(19):6781–6788. doi:10.1128/AEM.01658-12 43 Ana Sandoiu, “How humidity may affect COVID-19 outcome,” Medical News Today, April 2, 2020, https://www.medicalnewstoday. com/articles/how-humidity-may-affect-covid-19-outcome.html 44 Viner, et. al., “School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review,” The Lancet: Child and Adolescent Health, April 6,2020. Doi: https://doi.org/10.1016/S2352-4642(20)30095-X 45 World Health Organization (2020), “Considerations for school-related public health measures in the context of COVID-19,” May 10, 2020. WHO/2019-nCoV/Adjusting_PH_measures/Schools/2020.1 46 CDC, K-12 Schools and Child Care Programs FAQs for Administrators, Teachers, and Parents 3/19/20,https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/ schools-faq.html

12

Strategies for Infection Control in K-12 Schools June 11, 2020

Icon Credit “Clinic” by Alice Design, from thenounproject.com “Covid-19” by OCHA Visual, from thenounproject.com “Maintenance” by Vectors Market, from thenounproject.com ”Apps” by Three Six Five, from thenounproject.com ”Barrier” by Vadim Solomakhin, from thenounproject.com ”Car” by Cho Nix, from thenounproject.com ”Checklist” by ulimicon, from thenounproject.com ”Circulation” by Timofey Rostilov, from thenounproject.com ”Clean” by Flatart, from thenounproject.com ”Clean” by Vadim Solomakhin, from thenounproject.com ”Cleaning” by Flatart, from thenounproject.com ”Clock” by AFY Studio, from thenounproject.com ”Constructions” by Komkrit Noenpoempisut, from thenounproject.com ”Copper” by Alejandro Dorantes, from thenounproject.com ”Curriculum” by Massupa Kaewgahya, from thenounproject.com ”Desk” by Creaticca Creative Agency, from thenounproject.com ”Door” Orin zuu, from thenounproject.com ”Farewell” by Fahmihorizon, from thenounproject.com ”Filter” by Dika Darma, from thenounproject.com ”Hand Dryer” by Manthana Chaiwong, from thenounproject.com ”Hand Sanitizer” by Andi Nur Abdillah, from thenounproject.com ”Health” by Akriti Bhusal, from thenounproject.com ”Home” by AlePio, from thenounproject.com ”Humidity Percent” by Martin, from thenounproject.com ”Light” by iconeu, from thenounproject.com ”Lunch” by Berkah Icon, from thenounproject.com ”Man” by Gan Khoon Lay, from thenounproject.com ”Medical Mask” by myiconfinder, from thenounproject.com ”People” by Ivan Luiz, from thenounproject.com ”Place” by Gagana, from thenounproject.com ”Playground” by Bartama Graphic, from thenounproject.com ”Policy” by Adrien Coquet, from thenounproject.com ”Risks” by Ralf Schmitzer, from thenounproject.com ”Running” by Luis Prado, from thenounproject.com ”School” by Firza Alamsyah, from thenounproject.com ”Social Distancing” by OCHA Visual, from thenounproject.com ”Teacher” by Gan Khoon Lay, from thenounproject.com ”Technology” by Wenjie, from thenounproject.com ”Thermometer” by monkik, from thenounproject.com ”Tools” by tezar tantular, from thenounproject.com ”Touch” by Adrien Coquet, from thenounproject.com ”Trees” by Made x Made, from thenounproject.com ”Vent” by Andrejs Kirma, from thenounproject.com

Copyright © Elevar Design Group All Rights Reserved

Elevar Design Group Regan Henry, Lisa Cameron Gulley, Cyndi Klein, Tony Lozier

13