Understanding What is Going on with COVID and a Guide to Making Decisions for Parents, Teachers, and School Board Members

How a viral illness impacts a population will be influenced by the behavior of the virus and the behavior of the people.

Background

What we are seeing today is a consequence of our failure to aggressively decrease the transmission of the virus. The SARS-CoV-2 virus, which causes COVID, is an RNA virus, as opposed to a DNA virus. RNA viruses are well known to mutate frequently.

When the SARS-Co-V-2 virus infects a person, some of the virus will be destroyed by the body’s innate immune system. This is the part of our immune system that can attack invaders without ever having been exposed to the invader before. This is the part of the immune system that gives you a sore or red or swollen arm in the hours and first few days after a vaccination, and may cause some people to have fever, chills, headache and other symptoms that generally resolve after a few days. This is because the innate immune system recognizes the vaccine as something foreign and begins attacking it. That is good, because an activated innate immune system will sound the alarm, so to speak, for antibodies to be produced (this is called humoral immunity) and certain white blood cells (this is called cellular immunity) to be activated (among these are T-cells) that are quite important to both defeating an infection and providing you with the ability to respond quickly if the virus ever tries to infect you in the future.

The virus that escapes the innate immune system then tries to enter cells. There are two ways that the virus can enter cells, but the way most of you have heard is that it binds to the ACE-2 receptor on certain cells (ACE-2 receptors can be found on the cells lining our nasal passages, our lungs, our blood vessels, our heart, our kidneys, our pancreas, our intestines and many other tissues).

The reason that the virus wants to enter cells is that it cannot replicate (i.e., make more viruses) unless it can use the machinery contained within cells to make more virus. There is only one thing, at this point, that can stop whatever virus escapes the innate immune system from entering cells and that is antibodies. The problem is that it takes a week +/- a few days to produce these antibodies if you have never been exposed to this form of the virus before. This is why vaccination is so important, because it allows us to expose our immune system to the protein of the virus that we think is the best target for antibodies. This way, we make very strong antibodies (high levels of so-called “neutralizing antibodies” that are the ones most effective at interfering with the virus’ ability to enter cells) and very targeted antibodies, unlike the immune response which occurs to infection with the SARS-CoV-2 virus in which people generally make lower levels of neutralizing antibodies and more diverse antibodies that are targeted to many other proteins on the virus that do not appear to be very effective at stopping the virus from invading cells. This is why we recommend that all persons who previously had COVID get vaccinated as soon as they recover, in addition to the fact that someone who was previously infected with one form of the virus is likely to be subsequently exposed to more evolved variants in the future, and the lower level of neutralizing antibodies may not be sufficient to overcome the new variant’s ability to evade these antibodies. By being vaccinated, we reduce the time it takes to make antibodies in response to an infection by many days so that these are present to stop the virus that gets past our innate immune system from entering cells. When virus levels are lowered, fewer cells are invaded and less virus can be produced, we get much less ill and we are less likely to be hospitalized, severely ill or even die. That is exactly what we are seeing happening with those who are vaccinated. When they get infected, they are not getting severely ill. Almost everyone with COVID in ICUs, on ventilators and who are dying are those who have not been vaccinated.

Once the virus gets into cells, antibodies can no longer get to the virus and the virus takes over the machinery in cells that allows cells to make proteins. Instead of the normal proteins a cell would make, the virus hijacks the production line and gives instructions for the manufacturing of more SARS-Co-V-2 virus. Those instructions are coded for in the RNA of the virus. Every time a new virus is being produced (and that can be millions of billions of times in a person who is infected), those instructions from the virus’ RNA are having to be copied and sent to the place in the cell where the virus is produced and assembled.

Now, imagine if I gave you a paragraph to copy a million times. What are the chances that you might make a transcribing error? Probably even greater if I told you that you have to write it quickly. These transcribing errors occur in the instructions for production of the virus, as well, and they are referred to as mutations. Most will be of no consequence and don’t change the inherent behavior of the virus. However, some are very significant because they may result in the virus being more contagious, producing more severe illness, and/or evading preexisting immunity to some degree (so-called immune evasion or immune escape). When a mutation occurs that gives the virus an advantage in infecting people, e.g., making the virus more contagious or helping it evade prior immunity, we call that a variant, and if these changes are significant, we call it a variant of concern. When a virus becomes more contagious and/or able to evade prior immunity to some extent, it now may have a “fitness advantage” over other viruses and over prior forms the same virus. The way we see this fitness advantage in real life is by the variant becoming the predominant circulating form of the virus, such as alpha did in March/April and now delta is today.

Last year, many were proposing that we should allow young people to go on with their lives since they were unlikely to die if infected, and this way they could get infected, develop immunity and we would be that much closer to “herd immunity.” I and others argued strongly against this strategy.

The first problem with the argument was the belief by some that achieving herd immunity through natural infection would be a desirable way to bring an end to the pandemic. [While there are disagreements as to whether this was or was not Sweden’s attempted strategy, Sweden’s approach most resembled what a country would do if this was the strategy, and I believe there is general consensus within and outside Sweden that whatever their strategy was, it failed miserably.] Instead, the wide-spread transmission of the virus has merely produced more contagious variants with increasing degrees of immune evasion that are further raising the bar for what it would take to achieve herd immunity, if that is even possible.

There were many problems with this proposed strategy. First, in the modern era of vaccines, I and all those I have asked were unsuccessful in coming up with an example of another viral disease for which herd immunity had been achieved through natural infection. Certainly, neither the U.S. nor the world has ever achieved herd immunity with any other known coronavirus. Second, no one knows the level of population immunity required for herd immunity for this novel virus. Given that the R-naught (R0 or reproduction number) was 2.2 – 2.7 for the original SARS-CoV-2 virus back in December of 2019 (and there are some that believe the true number could be almost double this due to instances of so-called “super spreaders” who end up infecting large numbers of people) at the very beginning of the outbreak, with no one having pre-existing immunity and with no mitigation measures in place, a person infected with SARS-CoV-2 would be expected to infect 2.2 to 2.7 additional people. The mathematical model would then predict that herd immunity would require that roughly 60 percent of the population be immune to safeguard vulnerable individuals within the herd from infection. While these data points were based upon the original SARS-CoV-2 virus circulating at that time, variants have arisen due to the uncontrolled transmission of the virus across the world. Some of these variants have enhanced transmissibility, and because of this biological advantage, have become the dominant forms of the virus in many parts of the world. An increase in contagiousness or transmissibility means that the reproductive number has increased. The so-called delta variant is currently rising in prevalence in the U.S. and is known to be considerably more transmissible with a reproduction number estimated to perhaps be as high as 8. It is now estimated that herd immunity may require up to 85% of the population to be immune, though there is increasing skepticism as to whether herd immunity can ever be achieved with this virus.

Though New York City became an epicenter of COVID activity in March of 2020, with overwhelmed hospitals and health care workers and an excessive mortality rate compared to many other countries, including China, a seroprevalence study conducted in New York City at the end of March 2020 indicated only 22.7 percent of the population had antibodies to the SARS-CoV-2 spike protein.[i] If the mathematical projections were anywhere near correct in the estimation of immunity required in the population for herd immunity, New York City was far from it. Therefore, those who advocated for this strategy risked overwhelming the country’s health care system and causing large numbers of deaths, not to mention the health care costs that would be associated with such resource-intensive hospital care.

These arguments in support of herd immunity, some of which continued to be made in the White House in 2020, became even more outrageous and irresponsible as we entered into clinical trials for vaccines and two mRNA vaccines were shown safe and effective in phase III trials, ultimately receiving emergency use authorizations from the FDA before the end of the 2020.

A third problem with the arguments in favor of achieving herd immunity through natural infection was a huge problem concerning the very foundation for herd immunity – individual immunity. In 2020, we simply did not know whether people who recovered from SARS-CoV-2 infection were immune; whether everyone was immune, including those with asymptomatic or mild infections; and if so, for how long, and whether natural immunity would be protective against variants that would develop over time. We certainly could detect antibodies to the spike protein in most people following infection, but the messaging to the public that the presence of antibodies does not necessarily mean immunity was a challenging one being contrary to commonly held beliefs. Further, with continued high levels of disease transmission around the globe, many new variants of concern have emerged, and no doubt, more will continue to develop, some already demonstrating a degree of immune escape/evasion. Unless immunity to the wild-type virus or prior variants will continue to protect the population from these new variants, any herd immunity developed will be short-lived if new variants spread and have significant and effective immune evasion/escape capabilities.

Early studies showed that while most (but not all) persons mounted an IgG antibody response to infection, few people made high levels of neutralizing antibodies and most people made some, but low levels of neutralizing antibodies. Further, antibody titers tended to decline significantly over two to three months, with some people becoming seronegative. While these data were generally discouraging, we still did not know the indicators of immunity for this disease and therefore, while we suspected that any immunity gained from natural infection might be short-lived (on the order of perhaps 3- 6 months as is typical for other more common coronaviruses), declining levels of IgG antibodies would not necessarily imply a loss of immunity, especially given that we had little data on the cellular immune response to this disease. We would subsequently learn that the protection provided by the mRNA vaccines was far more robust than expected, with adequate protection maintained at one year, and many speculating that protection may last for a number of years, and that in those persons who had COVID and subsequently were vaccinated, there might even be life-time protection.

Though it was difficult to document cases of reinfection because testing was generally by nucleic amplification methods (PCR), which did not preserve a sample of the virus for genetic sequencing, there have been, as of the time of this writing, 169 documented cases with three resulting in death and 82,148 suspected cases of reinfection with 299 resulting in death. Supporting impressions that immunity from the SARS-CoV-2 virus infection may be short-lived, the average time interval between infection and reinfection for the confirmed cases was 115 days.[ii] While with other infections, we often see that a reinfection is milder than the initial infection, that was not true in every case with COVID, including instances where the reinfection was serious enough to require hospitalization and three cases of documented reinfection in which the patient died as a consequence of the reinfection.

The fourth problem was while many of those who advocated for a rush to herd immunity through natural infection considered the U.S. case fatality rate at the time of 1.77% to be low and acceptable, there was generally no consideration or accounting given to the emerging evidence of morbidity associated with COVID. Unfortunately, we are identifying more and more long-term consequences of COVID in those who survive, including those who experience mild disease, that affect their health, cognitive functioning, mental health and well-being.

Delta

So, with this background, what is different about delta and what does this all mean?

As a consequence of uncontrolled transmission, delta has acquired mutations that are serious enough to make it a variant of concern. We have evidence that it is far more contagious and it has acquired some degree of immune evasion, and it may have achieved the trifecta of also creating more severe disease.

Increased transmissibility

Transmissibility reflects how easily a virus spreads within a population. The basic reproduction (R0) and/or the secondary attack rates are often used to make inferences as to transmissibility of a virus. Transmissibility is determined by the infectivity of the virus, the contagiousness of the infected person, the susceptibility of those who are exposed to the person who is infected and environmental factors such as population density or distancing of persons and ventilation in the case of airborne viruses or sanitation practices in the case of food-borne illnesses, as well as the degree of existing immune protection within the population.

The CDC, WHO and a consensus of the world’s public health agencies and experts have concluded that delta is far more contagious and transmissible than the forms of the virus we have previously dealt with in the United States, including the most recently predominant alpha variant.

Public Health England has determined that the delta variant is more transmissible[iii]. A study in England confirmed that there was a significantly higher risk of transmission of COVID due to the delta variant in households than we experienced previously with alpha and prior forms of the virus.[iv] This study found a 64% increase in the odds of household transmission associated with infection with SARS-CoV-2 delta variant compared to alpha. It should be noted that prior to delta, alpha was the most contagious variant in the U.S. It should also be noted that this enhanced household transmission existed despite England having a higher vaccination rate than the U.S. Most cases of infection occurred in unvaccinated persons.

A study here in the U.S. has also confirmed high transmission rates within an indoor athletics facility[v] (in this case a gymnastics facility, but think office or school for other types of facilities) of 20% and a secondary attack rate in households of 53%. A total of 47 persons were infected in this outbreak – 23 gymnasts, 3 staff and 21 household members, although the authors acknowledge that the total number of infections may be underreported. The ages of those infected ranged from 5-years-old to 58-years-old. Two persons required hospitalization, including one who required intensive care. 85 percent of those infected were unvaccinated and six percent had only received the first dose of the two-shot series of vaccine. Only four of the 47 persons infected were fully vaccinated.

Of particular note for schools who in the last school year relied on pods or cohorting to limit outbreaks of infections, this gymnastics facility cohorted gymnasts by gender and skill into 16 groups, each with a different practice schedule, and yet this outbreak extended to ten of the cohorts. The staff indicated that cohorts had limited interaction with each other.

The conclusion of the authors was: “These findings suggest that the B.1.617.2 (delta) variant is highly transmissible in indoor sports settings and within households. Multicomponent prevention strategies (this means vaccination, masks, distancing, enhanced ventilation, etc.) … remain important to reduce the spread of SARS-CoV-2, including among persons participating in indoor sports and their contacts.”

The secondary attack rate of 53% in households (meaning what percent of household members become infected when another member of that household becomes infected) is further evidence of the increased transmissibility of the delta variant, as that attack rate was on the order of 17% with prior forms of the virus[vi]. This is important for school leaders and board members to appreciate, because while it remains true that a relatively low percentage of children become seriously ill or die, unlike last year when children played a limited role in the transmission of COVID, children appear to be far more efficient at transmitting delta. This should be of great concern due to the fact that in Idaho, only 34% of adults ages 25 – 34 are fully vaccinated and only 41% of adults ages 35 – 44 are fully vaccinated, and these would be the expected ages of the parents of school-aged children (household contacts). Thus, if schools do not require multicomponent or multi-layered prevention strategies in schools, we can expect to see much higher infection rates in the students’ households than we saw last year and because 1/2 – 2/3 of their parents remain not fully vaccinated, this poses a huge threat to overwhelm local hospitals[vii]. A discussion of mental health impacts to students will not be complete without the inclusion of the impacts to students who have a parent become seriously ill, or die, due to COVID that may impact the family’s income, whether the child has a surviving parent and if not, who will become the custodian of the child, and in those cases of an older child, the potential knowledge that they may have been the person to infect their parent.

Let’s talk big picture: the delta variant is more transmissible than the coronavirus that caused Middle East Respiratory Syndrome (2012), the coronavirus that caused Severe Adult Respiratory Syndrome (2003), the Ebola virus, the Poliovirus, the seasonal influenza viruses, the 1918 (“Spanish”) influenza virus, and the variola virus that causes Smallpox. You’ll recall from above that the reproduction number (meaning the number of people one person with infection would be expected to infect) for the SARS-CoV-2 virus was 2.2 – 2.7 at the beginning of the pandemic. It now appears that the reproductive number for the delta variant is about 8. That makes the delta variant of SARS-CoV-2 as transmissible as the varicella virus that causes Chickenpox.  Schools have a long history of dealing with childhood illnesses. For school leaders and board members, I am pretty certain that if you knew that there was a child in a class at your school with Chickenpox, you would immediately remove the student from other students and send the child home. My question then is why would you allow students with an equally transmissible virus to remain in your classrooms? Likely, your answer is because we can tell the child has Chickenpox, but we most often will not be able to tell that a child has COVID. True. And, that is why everyone needs to mask. Because with COVID, and especially with delta, children may very well be spreading this highly contagious disease with no one having any idea that the child is infected.

Increased contagiousness

Contagiousness, or the ability to infect someone else, is a factor in determining transmissibility, and in the case of delta, appears to be a significant factor.

There is an important study of an outbreak of COVID caused by the delta variant in which 1 person was responsible for an outbreak involving 167 others[viii]. We gained a lot of understanding because those who were exposed and quarantined were tested by PCR daily. Shockingly, when someone who was exposed first tested positive, they had viral loads 1260 times what we saw with the early forms of the virus. Viral load refers to the amount of virus in a person’s nasal passages. Viral load is important because the higher the load, the more likely someone is to transmit virus to someone else with whom they come into contact and the greater amount of virus the person exposed is likely to receive (the viral dose). There is evidence that the greater the viral dose, the more severe the infection is likely to be.

There are other implications from this study. Prior to delta, the time from exposure to the development of a positive test if the exposed person were to become infected was about 6 days. And, even then, it was not clear that the viral levels were high enough to efficiently transmit. In other words, if we could identify contacts within four or five days and get them to quarantine, we were very likely to prevent the contact who is now infected from infecting anyone else, other than household members. However, the authors of this study found that with delta, the average time from exposure to positive PCR test was 3.7 days, and that by the time they had a positive PCR test, they already had very high levels of virus that would pose a significant threat of transmission. So, our contact tracing efforts that were hugely helpful in containing the spread of infection in schools last year, may be far less effective with delta. Let’s take an example. Sue is an unvaccinated 12-year-old, in sixth grade who plays basketball. Sue is in a classroom with 20 students. She is on a basketball team with 12 students. The school leaders do not require masking or physical distancing, and therefore, there is no consistent physical distancing and the vast majority of students do not wear masks, even though in Idaho only 16 percent of students ages 12 – 15 are fully vaccinated (I only make reference to fully vaccinated rates, because unlike prior forms of the virus where even one dose of vaccine was very protective, one dose provides little protection against delta). On Thursday, Sue begins to feel tired, fatigued and has a stuffy nose. Sue and her parents assume that Sue’s allergies are acting up. But, Sue powers through, especially since she is excited about her sleep-over with six friends on Friday night. On Saturday, Sue tells her parents that she is now getting a headache and feels worse and that this feels different from her allergies. Her parents take her in for a COVID test on Saturday afternoon. The test result comes back positive on Monday. Sue’s parents notify the school on Monday and her sleep-over friends’ parents Monday evening when those parents are home from work. It is at least day 5 for her classmates and basketball teammates and it is day 3 for her sleep-over friends. Let’s just take the 20 classmates. If 16 percent of them are fully vaccinated, that is 3 students who are fully protected. 17 students would be very vulnerable. Let’s take the facility attack rate observed with the gymnastics outbreak mentioned above of 20 percent. That would mean 3 – 4 students would be expected to be infected. However, by the time they realized they were exposed on day 5, they should all have high loads of virus and they will in turn have infected others. And, of course, this doesn’t account for other students infected by Sue through basketball, Sue’s use of the library, Sue passing other students or stopping to talk to them in the halls (reports out of Sydney, Australia suggest that the contact time for exposure may be very brief and that casual contact may be sufficient), and friends from other classes who join her for lunch. This example demonstrates how we may be more likely to experience outbreaks in school this fall with delta.

Increased severity of COVID

It appears that delta is capable of producing more severe disease than prior variants and forms of the SARS-CoV-2 virus did. A study from Canada showed that unvaccinated persons infected with delta had a little over two times the likelihood of hospitalization, almost four times the chance or requiring critical care and a little over two times the risk of dying compared to persons infected with prior variants of the virus[ix]. A study out of Singapore also showed higher odds of requiring oxygen, critical care and dying with COVID caused by delta compared to other variants[x]. And, similarly, a study out of Scotland showed that an unvaccinated person with COVID caused by delta was almost twice as likely to require hospitalization as someone with COVID caused by other variants[xi].

So why do I need to wear a mask if I am vaccinated?

Let’s be clear. The vaccines are extremely effective, but no vaccine is 100% effective and the vaccines were designed to prevent us from becoming severely ill, requiring hospitalization or dying, not to prevent infection even if mild or asymptomatic. If fully vaccinated, you have an 8-fold reduction in the incidence of becoming symptomatically ill with COVID. So, even though we do get a lot of protection from the possibility of becoming ill with COVID if we are fully vaccinated, with 162 million vaccinated Americans, it still means that 34,020 will develop symptomatic COVID per week. On the other hand, the chance of a fully vaccinated person requiring hospitalization or dying from COVID is reduced by a factor of 25 compared to someone who is not vaccinated, which means that we would only expect 162 fully vaccinated Americans to be hospitalized each week and only 6.5 deaths from COVID among the fully vaccinated each week. For comparison, just in Idaho, and currently, our state is not yet being impacted anywhere nearly as bad as many other states, we had 2,259 COVID cases and 14 deaths in the past week. Thus, we would anticipate far fewer cases, hospitalizations and deaths in the entire country among those who are fully vaccinated than the corresponding numbers just in the state of Idaho.

Prior to delta, a study showed that vaccination reduced the viral load in those who became infected by 40 percent and that virus was detectable for a shorter period of time (2.7 days in fully vaccinated persons vs. 8.9 days in others)[xii]. However, with delta, fully vaccinated persons who become infected have viral loads that are comparable to the loads of those who are unvaccinated. So, while the fully vaccinated are highly protected against severe disease, hospitalization and death, we face a dangerous public health situation in which the fully vaccinated may become infected, remain asymptomatic or mildly symptomatic such that they do not realize they are infected, and continue normal interactions because of their vaccination status without wearing a mask based on prior CDC recommendations, while actually playing a significant role in the transmission of the virus. For schools, this means all staff and faculty must wear masks in order to avoid inadvertently creating an outbreak of delta infections among their unvaccinated students.

In addition, the CDC examined 469 cases of COVID occurring in July of this year related to summer events or large gatherings in a town in Massachusetts.[xiii] Sequencing from 133 of those infected confirmed that their COVID was caused by the delta variant. This was of particular interest because Massachusetts reports a 69 percent vaccination rate among eligible residents, much higher than most states in the country. It was also notable because 74 percent of the infections occurred in fully vaccinated persons, and 79 percent of those persons were symptomatic. Four of the five persons hospitalized were fully vaccinated, but none died. Laboratory testing showed that those who were fully vaccinated, yet infected had similar viral loads as those who were unvaccinated and infected. Of note, persons with COVID-19 reported attending densely packed indoor and outdoor events at venues that included bars, restaurants, guest houses, and rental homes.

This town is host to tourists. It is shocking to see how quickly dangerous levels of community spread can occur. On July 3, the MA Department of Public Health had reported a 14-day average COVID-19 incidence of zero cases per 100,000 persons per day in residents of the town in Barnstable County; by July 17, the 14-day average incidence increased to 177 cases per 100,000 persons per day in residents of the town. This is evidence once again, that a 69 percent vaccination rate among those eligible to be vaccinated is not sufficient for “herd immunity,” and that those who are unvaccinated and unmasked present a considerable threat to those who are vaccinated. As long as we have a large number of unvaccinated who are driving transmission and the development of new variants, vaccination by itself is not a sufficient protection from the vaccinated playing an unwilling participant in the transmission chain. Not surprisingly, large gatherings with persons that you do not know without physical distancing remains a high-risk activity for all until we can gain control of the spread of this disease.

With respect to schools, all of the above should certainly be evidence that those staff and teachers who are unvaccinated are at risk for severe COVID Further, vaccinated staff and teachers need to be in an environment where everyone is masked in order to avoid transmitting the virus to friends and family even though they themselves would not be expected to get severe disease.

What is at risk if school boards act recklessly?

First of all, if schools cave to pressure to have all students back for in-person without distancing and without masks, based on all of the above, one would have to imagine there would be a significant chance for a widespread outbreak, which of course would send everyone to remote. Thus, they risk pleasing parents for a short time, but then enraging them when kids now all have to learn at home. And, of course, none of those parents will rush to defend board members or school leaders for doing what the parents wanted. This approach seems short-sighted.

It is still anticipated that all school-aged children will be able to be vaccinated in the first part of 2022. Therefore, a mask requirement would likely not be needed for the entire year, but just until children could reasonably complete the vaccine series. Further, schools benefit financially from children being in person each day. Without a mask requirement, large numbers of children will have to be isolated and others quarantined. Much of this could be avoided with masks and reasonable efforts at distancing. A side benefit is that masking would decrease many other respiratory infections, especially influenza. Again, this would improve attendance and financially benefit the school district. There is no reason that children cannot be in full, in-person attendance, but with appropriate protections.

Further, schools need to help society in decreasing the transmission of this virus. As I mentioned above, the failure to control the transmission of this virus will inevitably result in more variants of concern, perhaps even more contagious, perhaps causing more severe disease and perhaps evading the protections of the vaccine even more significantly. A recent modelling study revealed that “a fast rate of vaccination decreases the probability of emergence of a resistant strain. Counterintuitively, when a relaxation of non-pharmaceutical interventions happened at a time when most individuals of the population have already been vaccinated the probability of emergence of a resistant strain was greatly increased. Consequently, we show that a period of transmission reduction close to the end of the vaccination campaign can substantially reduce the probability of resistant strain establishment. Our results suggest that policymakers and individuals should consider maintaining non-pharmaceutical interventions and transmission-reducing behaviours throughout the entire vaccination period.”[xiv] This actually makes sense because, as a large part of the population becomes immune to one form of the virus, that strain no longer circulates and can open the door to a new form of the virus with immune evasion capabilities, even if that new variant would not have been as fit and would not have been able to compete well with the prior variant. We believe that we saw this play out in South America. As the authors put it: “Our model shows that if at the time a vaccine campaign is close to finishing and nonpharmacological interventions are maintained, then there’s a chance to completely remove the vaccine-resistant mutations from the virus population.”

Besides the potential for backfire and the potential that schools contribute to community spread and the development of more problematic variants are the more fundamental questions. Can we expect schools to follow science? Can we expect school leaders and board members to protect students and their families? Can we expect board members to put the welfare of students, their families and our communities ahead of their own self-interests? Do school boards have a responsibility to ensure that they do not inadvertently contribute to community spread of this disease and overwhelming of local hospitals? Ultimately, if there are widespread outbreaks, deaths and long-term health consequences to children and their families, then I suspect we will see taxpayers pay for the potential large liability created by “reckless infliction of harm” on the part of school boards that is excepted from limited liability protection provided by the legislature. I hope it does not come to this. Schools and school leaders should place a high value on science, knowledge and truth. In the end, even if school leaders and school boards fail us, truth will still be truth and this virus will do what it will do. It has already been providing us with the preview of coming attractions.


[i] “Cumulative incidence and diagnosis of SARS-CoV-2 infection in New York.” Rosenberg E S et al. Annals of Epidemiology. 48: 23-29.e4, August 2020. https://doi.org/10.1016/j.annepidem.2020.06.004.

[ii] COVID-19 reinfection tracker. BNO News. Bnonews.com/index.php/2020/08/covid-19-reinfection-tracker/.

[iii] Public Health England. SARS-CoV-2 variants of concern and variants under investigation in England—technical briefing 17. London, United Kingdom: Public Health England; 2021. https://assets.publishing.service. gov.uk/government/uploads/system/uploads/attachment data/ file/997418/Variants_of_Concern_VOC_Technical_Briefing_17.pdf

[iv] https://khub.net/documents/135939561/405676950/Increased+Household+Transmission+of+COVID-19+Cases+-+national+case+study.pdf/7f7764fb-ecb0-da31-77b3-b1a8ef7be9aa.

[v] https://kfor.com/wp-content/uploads/sites/3/2021/07/Click-here-to-read-the-full-report.-1.pdf.

[vi] Madewell ZJ, Yang Y, Longini IM Jr, Halloran ME, Dean NE. Household transmission of SARS-CoV-2: a systematic review and meta-analysis. JAMA Netw Open 2020;3:e2031756. PMID:33315116 https://doi. org/10.1001/jamanetworkopen.2020.31756.

[vii] Idaho’s ICUs are filling up again — this time, patients are in their 30s | Local News | postregister.com

[viii] https://virological.org/t/viral-infection-and-transmission-in-a-large-well-traced-outbreak-caused-by-the-delta-sars-cov-2-variant/724.

[ix] Fisman and Tuite, doi:10.1101/2021.07.05.21260050.

[x] Ong et al. doi:10.2139/ssrn.3861566.

[xi] Sheikh et al. doi:10.1016/S0140- 6736(21)01358-1.

[xii] Thompson et al. doi:10.1056/NEJMoa2107058.

[xiii] Outbreak of SARS-CoV-2 Infections, Including COVID-19 Vaccine Breakthrough Infections, Associated with Large Public Gatherings — Barnstable County, Massachusetts, July 2021 | MMWR (cdc.gov)

[xiv] Rates of SARS-CoV-2 transmission and vaccination impact the fate of vaccine-resistant strains | Scientific Reports (nature.com)

17 thoughts on “Understanding What is Going on with COVID and a Guide to Making Decisions for Parents, Teachers, and School Board Members

  1. Dear Dr. Pate, first thanks for your information, mostly I believed is extensive but good, some inn my point of view is just to people get more scare than need to be which puts people in more stress and as result their immune system will weaken.
    My main frustration and concern is at the beginning of the pandemic we saw how the most affected were seniors and health vulnerable people but it seams that no body and I am talking a government level is conscious about improving the level of people’s immune system, all campaigns are for vaccine but no campaigns educating people making better choice in their food, teaching ways to relax, helping families to have access to places were is fun but to expensive to afford, and teaching many other ways that help people to get mind, body and spirit in better shape.
    If we have a new pandemic in the next 10 years we again will be lost and many people will lose life and that is a concern.
    We relay to much in medicines and vaccines but we forget that God create our bodies in a perfect manner.

    Thanks for listening.

    Ximena S Luna

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    1. Hi Ximena,

      You are certainly correct that we must work to improve the health of the people of the world prior to the next pandemic. However, for this pandemic, general health measures and/or targeted efforts to optimize the functioning of our immune systems (adequate sleep, vitamin D supplementation, etc.) will not be sufficient to prevent infection or severe outcomes. There is no better option than vaccination (other than isolation) for the prevention of severe outcomes from COVID.

      Also, I would point out that the Bible teaches us that God’s creation was perfect, but then made imperfect by sin, in fact, by original sin. As a consequence, our bodies are corrupted and we are subject to disease, disability and death. God ultimately restores His perfect creation and gives those who are saved new, incorruptible bodies, but for now, we are all imperfect and we must do what we can to protect ourselves, our family members and our neighbors by getting vaccinated.

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  2. Dr. Pate: Please help me interpret the results of the Barnstable County study quoted here. It claims that “74 percent of the (469) cases occurred in fully vaccinated persons.” This seems highly at odds with the claims of a 94-95 percent effectiveness made about the Pfizer and Moderna vaccines and even the roughly 66 percent claimed about the J and J vaccine. Can it just be coincidence that the all the people infected in this study fall into the 5-6 percent for whom the Moderna/Pfizer vaccines weren’t effective? Or the 34 percent for whom J and J wasn’t effective? The numbers get confusing, but how can the infection rate among the vaccinated be so high, especially when only 28 percent of those cases were caused by the (potentially more vaccine resistant) Delta variant? Perhaps I’ve missed something, but those numbers don’t add up.

    Also, it seems like this data may well serve as ammunition for the anti-vaxxers who like to use statistics like this to claim that the vaccines don’t work anyway. But why are they wrong in this case?

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    1. Josh,
      Excellent questions. Here are my thoughts.
      1. Keep in mind that the 94-95% efficacy reported for the vaccines was back in mid-to-late fall 2020, prior to the delta variant and in those who were tested in the clinical trials. First, real-world effectiveness will always be a bit lower than the clinical trial efficacy results because trials usually exclude people who will be at risk of the vaccines not inducing as strong a response, such as those who have cancers undergoing chemotherapy and those with immunocompromise due to disease or the therapies being used to treat the disease. Second, because of our failure to slow the transmission of the virus, the fears that we had that variants might develop with some degree of immune escape/evasion capabilities has come to fruition with delta. Thus, estimates in the U.S. have suggested that with delta, the efficacy of these vaccines probably decreased from 94-95% to somewhere in the high 80s. But, studies in Israel, suggest that the efficacy has dropped down into the 60s. Thus, we are going to see more breakthroughs in fully vaccinated people with delta than what we have previously seen with alpha and the other prior forms of the virus.
      2. I think the CDC has unintentionally misled people when they have said previously that breakthrough infections were “rare.” That is because they have only been tracking breakthrough infections that result in hospitalization. Those are rare. However, I have seen a surprisingly large number of breakthrough infections in people who were asymptomatic or only mildly ill, not requiring hospitalization, and so in some ways I was not overly shocked by this Barnstable County study. I think mild breakthrough infections are not rare with delta. On the other hand, the vaccines are still doing an incredibly good job at preventing these persons with breakthrough infections from becoming severely ill, getting hospitalized or dying. The mere fact that 96+% of all persons hospitalized with COVID are unvaccinated, even at a time when I suspect we have many more breakthrough infections than reported, is strong evidence that these vaccines are very effective.
      3. So, I don’t think we should be concerned about the surprisingly high percentage of persons who got infected in this outbreak, per se. I think that there are three other things we should be concerned about. One is that this is one of the best documented examples that people who are taking all the recommended precautions and are getting vaccinated are still being endangered by those who refuse to do so. Second, while I welcomed the new CDC guidance, I winced when they qualified their guidance just for areas with high or substantial transmission rates. That would not have applied to this county prior to the outbreak. This is a reminder that even in high vaccination areas of the country, we have not hit herd immunity and we should not be relying on vaccination alone while we have so much transmission, travel and people who remain vulnerable, especially with a more contagious new variant. Lastly, we should be concerned that these vaccinated persons with breakthrough infections can be part of the transmission chain, even if they are asymptomatic. This is the main reason that we need to go back to people who are vaccinated wearing masks.
      4. Lastly, note that the authors of this study mention that these folks were in very crowded, close contact both indoors and outdoors. Large gatherings and close contact with people who we don’t live with is still something to be avoided at present, until we get better control of the pandemic. It is an important reminder that while everyone is definitely safer outside (because you have less if any airborne transmission), but if you gather in very close contact outside (concerts, rallies, etc.) with a far more contagious variant (delta), you can still transmit the virus efficiently through respiratory droplets.

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      1. Thank you. Very helpful.

        I’m going round and round with the superintendent and West Ada board on masking. And they continue to say they’re listening to health authority guidance and data all while refusing to implement as mask mandate (as Boise just did). Further, the superintendent refuses to add a discussion of masking as an agenda/action item at next week’s board meeting so parent’s won’t be allowed to speak publicly on the matter. I spent 34 minutes on the phone with Dr. Bub yesterday to no avail. I’d love to know what’s really motivating his actions. Because it’s not what he says it is.

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      2. I can’t figure it out, either. They are not listening to science or experts. When they didn’t like my advice, they fired me. When they didn’t like the fact that the doctor they replaced me with gave them the same advice, they fired him. I don’t think they understand how different delta is from what they dealt with last year and I’m not even sure they are trying. I’m guessing this is to please the outspoken parents. But, they would be wise to look at what is happening with the many outbreaks that have already happened with schools that opened last week or the week before. The parents now are mad because their kids are remote and/or in quarantine and they are mad at the same leaders and board members who gave them what they wanted – no masks. My advice to Dr. Bub – when you are in a no-win situation; do the right thing. You are going to make people unhappy and be blamed no matter what, so at least be able to tell your next prospective employer that you did the right thing.

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  3. Hi, David—

    Your blog is amazing. Terrific information, beautifully presented. BUT—I just don’t have time to read all this, even though I’m very interested in your point of view. How about providing an executive summary of key points at the beginning? Then follow with the whole piece. I’ll bet a lot more time-constricted people would absorb and benefit from your opinions, while people who need to know all the details would benefit from reading the entire blog.

    Thanks so much for continuing to work on this important topic.

    Best—Alice

    >

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    1. Alice,
      Fantastic suggestion, as always! I will start putting key takeaways at the beginning of my future blog posts.
      It is quite a coincidence that something made me think of you yesterday and wonder how you were doing, and then I hear from you today! I have always benefited from your excellent ideas. Thank you!

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  4. I also have been going rounds with West Ada and the superintendent. I feel like he wants to find a middle of the road approach which I can understand, but it just doesn’t feel like that’s a reasonable option here. Waiting to put masks on until there’s an outbreak is stupid. You mask up to avoid the outbreak. He did mention that he’s meeting with medical professionals next Tuesday, and I certainly hope that involves you.

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    1. You’re absolutely right. The school outbreaks we are seeing in other parts of the country that have already started school and without a requirement of masks have resulted in large outbreaks in just days, with some schools having to go remote and others reporting as many as 100 students in quarantine.
      I am glad they are seeking the advice of medical professionals, but they have not asked me. I haven’t had any contact with them for nearly 5 months. That is fine. There are a number of other physicians who could certainly do this. However, I do know that some of the board members follow my social media, so its not like I haven’t been clear!

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  5. I also have been going rounds with West Ada and the superintendent. I feel like he wants to find a middle of the road approach which I can understand, but it just doesn’t feel like that’s a reasonable option here. Waiting to put masks on until there’s an outbreak is stupid. You mask up to avoid the outbreak. He did mention that he’s meeting with medical professionals next Tuesday, and I certainly hope that involves you.

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  6. You are so awesome! I don’t suppose I have read anything like that before. So good to find another person with a few genuine thoughts on this subject matter. Really.. thanks for starting this up. This web site is something that is required on the web, someone with a little originality!

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  7. Dr. Pate

    You addressed my subject briefly earlier, but to be more specific, I just heard, not intending to, that there are heavy metals in the vaccine which causes the red blood cells to become elongated thus causing the blood to clott. Your thoughts? Thank you so much for blog! It has been a blessing to me and many many others.

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    1. Hi Terry,

      No, neither the Pfizer nor the Moderna vaccines have heavy metals in them. I am afraid that this is misinformation circulating on social media, but without any basis in fact. Neither the Pfizer nor the Moderna vaccines cause changes to your blood cells causing them to clot.

      Thanks for raising this question so that I could answer it for others, as well. Take care and be safe!

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  8. Dr. Pate,

    Can you reply to the comments made by Dr. Cole at the August 26 board meeting of the Peace Valley Charter school in Boise? The full story is available here (https://www.idahostatesman.com/article253945878.html). He said the following:

    “As much as we would like to think that masking our children does something, statistically there’s never been one randomized control trial that shows masks to stop a spread of a viral airborne illness, especially cloth masks, so there’s really statistically no efficacy in masks.”

    I’m unsure if this statement regarding randomized control trials is true. But I’m fairly certain that it doesn’t need to be true given the other data we have to support the efficacy of masking in helping control Covid spread.

    He also said the following regarding hypercapnia. It’s directly refuted on the CDC’s page regarding masking (https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html), but I’m curious to hear your view.

    “Masks increase retained carbon dioxide and hypercapnia can cause brain fog, it can cause inflammation in the brain and can cause inflammation in the body,” he said. “And this is something we don’t hear enough of.”

    Finally, he said this:

    “I think we need to be prudent and say it’s time to let children be children, delta is going to spread, we cannot stop it,” he said. “Everybody’s essentially going to get it.”

    The notion that everyone is going to get it is a disturbing one. And it’s one that was also shared by Dr. Bramwell (who was strongly in support of masking) in the August 24 West Ada board meeting. What are your thoughts on stopping delta and on everyone getting it?

    Thanks,
    Josh

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    1. Hi Josh,
      It is a sad state of affairs that so much misinformation and disinformation is still promoted more than 18 months into this pandemic. In fact, much of this misinformation and disinformation is the very reason that we have not yet brought this pandemic under control.

      I only agree with one part of one sentence above. “…we cannot stop it.” That is true for those who refuse to wear masks and get vaccinated. If you refuse to do those things, you are a sitting duck. That may explain why no one in my extended family who has followed my advice has been infected. On the the other hand Dr. Cole got COVID about a month ago.

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