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