Issue No. 15

How to Live Safely With COVID-19? Here Are 13 Answers from a Global Forum

“There is a way forward, using the technology of the 21st Century, from masking to testing to improving indoor air quality.”
 
That was the conclusion of a virtual global forum titled, “Two Years of a Global Pandemic: Lessons Learned and Plans for the Future,” held on Jan. 19. ActivePure, the Dallas-based air and surface purification company, and the Employer Health Innovation Roundtable (EHIR) were the sponsors, and more than 600 people – corporate and health care executives and officials of federal, state, county, city and tribal governments – were enlightened by five experts from four continents.
 
The speakers were: Sen. Tom Daschle, former U.S. Senate Majority Leader and co-founder of the Bipartisan Policy Center; Dr. Eng Eong Ooi, co-director of Viral Research and Experimental Medicine at the Duke-National University of Singapore Academic Medical Center; Michael Conway, who has led the Global Health Policy Practice of McKinsey & Co.; Dr. Esper Georges Kallas, professor of Allergy and Immunopathology at the School of Medicine, University of Sao Paulo, Brazil; and Dr. Deborah Birx, former White House Coronavirus Coordinator and now Chief Scientific and Medical Advisor to ActivePure.
 
Here are some of the highlights, culled from the experts’ remarks and responses to questions:
 

• We are on a path to a new future, where COVID is a concern but not a crisis. The path has not been easy. In a pandemic, policy makers and corporate and health care leaders need to be honest that uncertainty exists. They have to strike a balance: provide clear and actionable advice but also acknowledge that there are things you just don’t know.”
• If nothing else, COVID has made us aware that there are tools to reduce the transmission of all infectious diseases. The pandemic has shown the government and the private sector that there is a long-term demand for finding ways to make indoor air and indoor services cleaner and safer.
• There will continue to be periodic surges across the world, independent of vaccines. These surges have become largely predictable, occurring every four to six months.
• Surges occur because natural infection with the SARS-CoV-2 virus or vaccination, even with boosts, does not result in long-lived protective immunity. Instead, immunity wanes, making people susceptible again to reinfection.
• Vaccines will protect against severe disease and death, but vaccinated individuals, not knowing that they are infected, often contribute to community spread – often putting the immunocompromised and the elderly in peril.
• Testing works to reduce spread. It lets you know you are asymptomatically infected so that you don’t go out and infect others. The U.K.’s aggressive testing has reduced hospitalization and death. Masks also work, particularly if you upgrade to the KN95 and the N95. So does improvement of interior air quality.
• Protecting the most vulnerable is crucial. In the U.S. there are seven to eight million people who are immunosuppressed and another 35 million that are over 70 years old – and may not have as a robust response to our current vaccines.

• COVID-19 ends when we learn as a community how to protect our individual families, and we learn in the workplace how to protect our vulnerable workers. The good news is that we have those tools now. The key is to deploy them so that everyone can return to work, return to schools, and that families can gather safely.
• There is a way forward, using the technology of the 21st Century, from masking to testing to improving indoor air quality.
• Singapore provides a lesson. It was shaped by its experience with the original 2003 SARS outbreak, which caught the nation by surprise and quickly spread through the hospital system. Many health care workers died. So when COVID came, Singapore and other Asian countries had procedures in place – a playbook to pull out and get things going.
• Throughout the world, buildings were not built with the prevention of aerosol spread of pathogens in mind. In homes, offices, schools, and shops, disease-prevention considerations need to be built in at the design stage rather than waiting for an outbreak to occur and then trying to retrofit.
• One of the reasons for new variants is low immunization coverage in many parts of the world. Africa is still less than 20% fully vaccinated. In populations with very low immunity, and particularly with immuno-compromised patients and others likely to harbor long-term infections, new variants will appear and spread around the world, as we have seen with Delta and Omicron. We should prioritize getting vaccines to the entire world.



• We can’t tell exactly where the pandemic will go, so the solution is to find 21st Century technological interventions that can contain not only Omicron but other variants that arise in the future. That means vaccines that are durable, work across variants, and protect against infection for a long time. It also means better therapeutics that treat COVID in the early stages, and it means much more testing, appropriate masking, protecting the most vulnerable, and improving indoor air quality to make interiors safe against not only SARS-CoV-2 but other pathogens.

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It Seems Nearly Every American Has Been
Infected With COVID

How many Americans have become infected with SARS-Cov-2, the virus that produces COVID-19? We really don’t know for sure, the range is somewhere between 25 percent (those documented) and 90 percent.
 
The official count of COVID cases as Feb. 2 was 75,600,000. But that figure misses millions of infections incurred by Americans who are asymptomatic or have such minor symptoms that they don’t know they have COVID. Cases also go unrecorded from people who find they are positive in a home test.
 
Taking these factors and others into account, the Centers for Disease Control and Prevention (CDC) estimates that only 1 in 4 COVID infections is officially counted. More precisely, the CDC determined that, with 95% confidence, actual infections are between 3.4 and 4.7 times greater than the reported figures. Multiply 75,302,000 by 4 and you get more than 300 million infections out of a population of 330 million.
 
That infection figure is eye-popping, but there is no way to tell if it is accurate. For one thing, the 4-1 ratio covers a period ending in September. Since then, cases have accelerated (one-third of all official pandemic infections have occurred in the past seven weeks), testing has accelerated, and methods of official counting have improved. Also, the 300 million number double- or triple-counts people who have been reinfected. The actual proportion of individual Americans infected by COVID over the past two years is probably closer to half or a little more. – still high.

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With So Many People Infected, Why No Herd Immunity?
 
Even if 50% of Americans have been infected, 64% have been “fully vaccinated” (a term that does not include boosters). Many of them, knowingly or not, have suffered breakthrough infections, so there is overlap between the infected group and the vaccinated group. But still, it is reasonable to assume that a significant majority in the U.S. has either had COVID, thus giving them natural immunity, or has had shots, thus giving them vaccinated immunity.
 
So doesn’t that mean that the U.S. should have herd immunity against COVID? As the Association of Professionals in Infection Control and Epidemiology defines it…
 
Herd immunity (or community immunity) occurs when a high percentage of the community is immune to a disease (through vaccination and/or prior illness), making the spread of this disease from person to person unlikely. Even individuals not vaccinated (such as newborns and the immunocompromised) are offered some protection because the disease has little opportunity to spread within the community.
 
For example, more than 90% of all children in the U.S. are vaccinated against measles, mumps and rubella by their second birthday. Even if a person with measles were to come to the U.S., write Johns Hopkins epidemiologists Gypsyamber D’Souza and David Dowdy, “nine out of ten people that person could infect would be immune, making it very hard for measles to spread in the population. As a result, even though we still see localized outbreaks in the U.S., those outbreaks generally die down without starting a nationwide epidemic.”
 
The main reason herd immunity has not ended the COVID-19 pandemic is that, unlike in the case of measles, the effects of both natural immunity and immunity acquired through vaccination declines fairly quickly over time.
 
First, understand that natural immunity is not particularly effective compared with vaccination. A study last fall, before Omicron appeared, found that people who had been infected with COVID during the prior three to six months but had not been vaccinated were about five and a half times more likely to have COVID-19 than those who had been fully vaccinated three to six months earlier.
 
Second, while vaccinations may beat natural immunity, they too waned in effectiveness. A study of Israeli health care workers, published Dec. 9 in the New England Journal of Medicine, concluded, “Six months after receipt of the second dose of the BNT162b2 vaccine, humoral response was substantially decreased, especially among men, among persons 65 years of age or older, and among persons with immunosuppression.”
 
In Issue No. 13 of this newsletter, we reported the results of a study released Dec. 14 by Wilfred F. Garcia-Beltran of Massachusetts General Hospital, Kerri J. St. Denis of the Ragon Institute in Cambridge, Mass., and 15 colleagues who examined sera (liquid separated from blood) from 239 individuals receiving a full series of Pfizer BioNTech, Moderna, or Johnson & Johnson vaccines; 71 of them also received boosters. The sera were then tested against the Omicron variant.

The researchers reported, “Remarkably, neutralization of Omicron was undetectable” in most of those who were fully vaccinated but unboosted, even if the vaccinations were completed just three months earlier. But those who were “boosted with mRNA vaccines exhibited potent neutralization of Omicron.” The researchers also found that Omicron “is more infectious than any other variant tested.”
 
On Jan. 27, the New England Journal of Medicine published a study by Nick Andrews of the UK Health Security Agency and colleagues that assessed 7.1 million SARS-CoV-2 PCR tests to analyze vaccine effectiveness declines over time. For persons in England ages 65 and older who received two doses of the Pfizer/BioNTech vaccine during the period when the Delta variant was dominant, effectiveness against symptomatic COVID two to nine weeks after the second shot was 80%, but by 20-24 weeks, effectiveness dropped to 55%. Effectiveness against hospitalization waned much more slowly for this age group: from 92% two to nine weeks after full vaccination to 80% in the 20-24-week post-vaccination period.
 
In addition, even before they begin to lose their potency, vaccines are far from perfect in preventing infection, especially against the Omicron virus. The CDC reports that for the week ending Dec. 25, 2021 (latest available), 444 fully vaccinated Americans per 100,000 population contracted COVID. That’s a lot of cases. Even among those with a booster dose, the rate was 305 – far less than the 1,174 among the unvaccinated but still enough to spread the virus effectively throughout the population.

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The Waning of Immunity Helps Explain Surges
 
The waning of both natural immunity and vaccine effectiveness goes a long way toward explaining the pattern of surges. Because of a new variant or increased indoor activity due to weather, a super-spreader event over a holiday, or simply the passage of time, cases can suddenly accelerate. COVID races through the population, but as more and more people in a community become infected, they acquire natural immunity, which leaves fewer naïve subjects available for the virus.
 
In addition, a surge in infections and overwhelmed hospitals cause governments to issue stricter controls and, just as important, individuals themselves to become more careful about dining indoors, gathering in large groups, or going maskless. People also get tested more often and expect that those with whom they associate to get tested, too. Infections decline – sharply.

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Cases Are Declining Sharply All Over the U.S.
 
That’s what we are seeing now in the United States. Cases soared from a seven-day daily average of 118,000 on Dec. 14 to 807,000 on Jan. 14 and then dropped precipitously by Feb. 4 to 318,000. That figure is still above last winter’s peak of 251,000, but cases today are falling sharply. Similar patterns are evident in South Africa, where Omicron was first seen and cases have now declined more than 80% from the peak, as well as the UK, France, Canada, and Italy, to name a few.

In the U.S., infections have dropped over the past two weeks in every state but Maine (where the increase was small). In Maryland, for example, daily average cases per 100,000 fell on Feb. 4 to just 28, compared with more than 200 three weeks earlier. New York’s rate has fallen to 45, down from more than 300 per 100,000. On the other hand, 12 states still have rates above 150, a level once considered disturbingly high.
 
The media narrative around this year’s winter surge was that, powered by the Omicron variant, it produced more infections but was otherwise “milder.” In fact, the daily peak (using a seven-day average) of hospitalizations was higher than last year: 159,000 vs. 136,000. Deaths are considerably lower: 2,600 vs. 3,300, but mortality is still rising. Let’s put this surge in perspective: Since Sept. 1, about 200,000 Americans have died; that is more, in less than six months, than die in a year from accidents, stroke, or Alzheimer’s.

There is little evidence that the pattern of surges will end. Based on prior experience, we can expect a small surge beginning in early April and a much greater one starting in late June when the heat drives people indoors.

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Conclusions from the COVID Model
 
What conclusions can we draw from this natural history of COVID?
 
First, we need vaccines whose protection last longer. If that is not possible, then boosters will be necessary every four to six months. A study published on Jan. 28 in CDC’s Morbidity and Mortality Weekly Reports (MMWR) found that receiving a booster increased the effectiveness of vaccination against hospitalization from 69% to 88% compared to just two shots of Pfizer or Moderna for immunocompromised individuals and from 82% to 97% for those who are not immunocompromised.
 
A separate study in MMWR on Jan. 21 found that unvaccinated individuals over age 65 were 10 times more likely to die of COVID than those who were fully vaccinated and 67 times more likely to die than boosted individuals.
 
So far, however, only 41.5% of the country’s fully vaccinated individuals have been boosted. That is about one-fourth the total U.S. population. What are the chances of most people getting a shot twice or three times a year?
 
Second, we need to accept and understand surges. They have a distinct seasonality because COVID is a disease transmitted almost entirely in interior spaces. In summer, especially in the South and Southwest, Americans move indoors, as they do in the winter nearly everywhere but states like Florida, Texas, Arizona and California. Pretending COVID does not exist is a recipe for disaster, but understanding that it will come and go allows us to build resilience through common sense measures like testing and masking.

Finally, we need to take steps to mitigate the virus not just during surges but on a sustainable basis. The best way to do that is through ventilation, filtration, and active cleaning of the air. Ventilation – that is, the exchange of air – may be necessary, but it is not sufficient (see below). To have a significant effect, HVAC systems require impractical, expensive, and emission-intensive amounts of energy. Filters and passive purifiers such as ionizers are inadequate. Early versions of photocatalytic oxidation produce dangerous products. Active cleaning, through a process such as Advanced Photocatalysis, has been shown to reduce 99.9% of pathogens, including enveloped viruses like SARS-CoV-2, in a matter of minutes, with safety.

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NASA Was the Source of Powerful Pandemic Fighters
 
“Clean Air Tech for Spacecraft Helps Fight Pandemic” was the headline of a Jan. 24 article in NASA’s publication on spinoffs from the space program.
 
“Early in the COVID-19 pandemic, as it be came clear that the novel coronavirus was transmitted through the air, several companies realized their NASA-derived air-quality technologies could help combat its spread,” the piece began. “And they soon found themselves overwhelmed by demand from schools to hospitals, shopping centers, office buildings, airports, and even buses.”
 
The article highlighted ActivePure (formerly Aerus), whose air-cleaning devices are now found around the world, including in dozens of operating rooms at the Cleveland Clinic and thousands of classrooms in the School District of Philadelphia. “Just after lockdowns took effect in March of 2020,” the piece stated, “Joe Urso, CEO and chairman of the Dallas-based company, said ActivePure had gone through six months’ worth of its inventory in the preceding weeks.”
 
All of ActivePure’s air purifiers, said the article, “are based on a technology developed in the 1990s at the Wisconsin Center for Space Automation and Robotics (WCSAR), a NASA Research Partnership Center at the University of Wisconsin-Madison at the time, sponsored by the space agency’s Marshall Space Flight Center in Huntsville, Alabama.”
 
Researchers there were tackling a problem involving tomatoes. Without gravity to move the air around, the plant hormone ethylene accumulated around plants, causing them to wither prematurely. The solution turned out to be a device that would produce photocatalytic oxidation, which works this way, according to the article:
 
Ultraviolet light hits titanium dioxide, a common, naturally occurring chemical compound installed inside the device. This releases electrons, which then combine with oxygen and water molecules in the surrounding air. The oxygen and water, now with a charge, attract organic contaminants, causing reactions that turn them into carbon dioxide and water. Among the pollutants destroyed are volatile organic compounds and other harmful or odor-causing chemicals, as well as mold spores, bacteria and viruses.
 
The article went on to say that “photocatalytic oxidation wasn’t the perfect solution.” The process can generate ozone, and organic compounds might be “only partially broken down.” Over the years, ActivePure has improved the process to tackle those problems. According to the NASA Spinoff article, testing has shown that ActivePure’s devices do not add ozone in the air. The piece went on:
 
Last summer, the U.S. Food & Drug Administration cleared ActivePure’s new Medical Guardian product as a medical device on the basis of its efficacy and safety, including assurance that it doesn’t cause concerning chemical by-products through partial oxidation.
 
Testing last year also showed that ActivePure “purifiers were effective in eliminating the SARS-CoV-2 virus,” said the article. The company now incorporates its advanced version of “photocatalytic oxidation into about 100 different air purifiers under several brand names, from portable units to those that fit in air ducts, cars, or elevators.”

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Chopping Bottoms Off Doors: A COVID Solution?
 
The Scottish national government just announced an unusual project to fight COVID: “cutting off the bottom of classroom doors in schools, as a means of improving ventilation.”
 
The UK Independent reported Feb. 3 that Scottish Education Secretary Shirley-Anne Somerville said that an estimated doors could benefit from being “undercut to increase air flow,” a plan that would cost an estimated $270,000.
 
The idea was ridiculed by political opponents of the Scottish National Party (SNP), part of Scotland’s ruling coalition. “If this issue wasn’t so serious, you’d be hard pressed not to laugh at this crackpot SNP proposal,” said Meghan Gallacher, Shadow Children’s Minister for the Scottish Conservative Party.
 
Scottish Liberal Democrats spokesman on education, Willie Rennie, asked, “Opening windows in winter and chopping up doors is an insult to the thousands of teachers and pupils who deserve a better solution to the problems of ventilation. Air filters could play a long-term solution with cutting the spread of other infections and improving conditions for good learning.”
 
The issue is more complicated than both the government and its critics seem to understand. In general, increased ventilation is beneficial to mitigating COVID-19, as long as ventilation means exchanging outside air for inside. Simply increasing airflow from an enclosed hallway into a classroom would seem to be a fruitless exercise, at best. Opening windows is a better approach, but it is impractical in a Scottish winter – and far from a panacea. But ventilation of any kind is not, by itself, a complete solution.
 
Strong cross-ventilation through banks of opposing windows failed to prevent widespread infection in a classroom in Marin County, California, in an incident thoroughly researched last year in MMWR. Twelve of 24 students in the classroom came down with COVID. In addition, 6 of 14 students tested in another classroom were infected. “The two classrooms were separated by a large outdoor courtyard…and doors and windows were left open,” said the study. Aerosols may have drifted from the first classroom, where a teacher was reading to students unmasked, to the second through those doors and windows. Doors open probably helped, rather than hindered, the spread.
 
As for ventilation through HVAC systems rather than open windows, caution is also advised. A study by Ahmed Sodiq and colleagues, published in the journal Environmental Research in August, warned of “the vulnerability of the conventional ventilation systems.”
 
The researchers wrote:
 
Indoor spread of infectious diseases may be assisted by the conditions of the HVAC systems…. The available reports have demonstrated that the virus, with average aerodynamic diameter up to 80–120 nm, is viable as aerosol in indoor atmosphere for more than 3 h, and its spread may be assisted by the HVAC systems.
 
Filters are no panacea either. In the Martin County case, according to the MMWR report, “All classrooms had portable high-efficiency particulate air filters.” In another example, published in the journal Infection Control and Hospital Epidemiology, filters in a hospital setting had little impact on protecting construction personnel from airborne Aspergillus, a type of mold that causes lung infections.
 
These passive HEPA systems are not designed to capture the smallest SARS-CoV-2 virus particles, and filters have to depend on the vagaries of airflow for the pathogens to reach the filter. Nor can filters destroy viruses on surfaces. Increasing the efficiency of a filter attached to an HVAC system from MERV-8 to MERV-13 can increase energy costs by up to 18%, with higher greenhouse gas emissions another consequence.
 
Scotland’s focus on the quality and safety of indoor air is absolutely correct, but the answer goes beyond chopping the bottoms off doors, opening windows, or beefing up ventilation systems and adding filters. What’s required is what NASA discovered many years ago: a chemical process that deactivates dangerous pathogens quickly and safely in both the air and on surfaces.