Clearing the air our kids share: a prescription for healthy schools [PODCAST]

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“Six air changes per hour and HEPA grade filtration of indoor air for our children is an investment in their futures for long beyond when the COVID-19 pandemic fades from view. We know there is poor indoor air quality in multiple schools, from inadequate ventilation to air pollution to wildfire smoke. Kids learn better and have less absenteeism in healthy air. COVID-19 has just added fuel to that fire. Let this be a torch to light our way forward to healthy indoor air- starting right now.

Most importantly, we need to make sure this opportunity is available to all children, particularly those who have often been left behind in this pandemic. Heartbreakingly, there are kids who never logged on last year or showed up to school, and may have families afraid to send them this year. There are federal funds available from the COVID-19 relief bills to ensure that we can provide this assistance even to already financially-distressed schools. Nothing will ever make our children completely safe, which is the persistent ache of being a parent. However, they deserve a school year in person if possible, and we as the adults in their lives, should do our best to make sure they get it.

Don’t buy your kids’ teachers apples this year. Get them some HEPA filters.”

Erika Maria Moseson is a pulmonary and critical care physician.

She shares her story and discusses her KevinMD article, “Clearing the air our kids share: a prescription for healthy schools.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Here in the show, we welcome back Erika Moseson. She is a pulmonary and critical care physician, and she wrote the KevinMD article “Clearing the air our kids share: a prescription for healthy schools.” Erika, welcome back to the show.

Erika Maria Moseson: Thank you very much. It’s great to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, for those who didn’t get a chance to listen to our first few episodes, just briefly share your story and journey to where you are today.

Erika Maria Moseson: Yeah, well, I’m a lung and ICU doctor, and a lot of times when I’m taking care of patients, I’m working really downstream from a lifetime of either smoking cigarettes, or being exposed to occupational hazards, or severe asthma caused by air pollution, but increasingly, out where I live on the West Coast, the health toll of wildfire smoke. And so I started a podcast and a website called Air Health, Our Health, really trying to focus upstream on the drivers of a lot of those things in the air we breathe, and underlying forces like climate change, tobacco industry hijinks, even forest management and wildfire resources.

It’s been a very creative and helpful outlet as a physician, when we’re all kind of trying to battle burnout right now. And so I really think trying to focus upstream on what’s landing everyone in the ICU, especially in the times of COVID, has been good for my mental health as well.

Kevin Pho: By the time this episode comes out, we’re going to be in the midst of the omicron variant. For those who are on the fence when it comes to getting vaccinated, can you paint this picture of what you’re seeing in the ICU today?

Erika Maria Moseson: Well, honestly, it’s increasingly a disease of the unvaccinated, and it’s really heartbreaking. One of the most important things I need to know about someone who ends up in the ICU is honestly whether or not they’re vaccinated, because it tells me so much about their prognosis. And it’s been awful. I’ve had husbands and wives dying together in my ICU. I’ve been talking to their children. We get to know people over the course of several weeks, because these are prolonged, horrible ICU stays with intubation, proning, blood clots, multiple complications, perforated lungs, and chest tubes, and their families go on this roller coaster with us. And frequently people don’t make it, especially if they’re intubated, especially with the delta variant, and who knows what the omicron variant is going to bring.

It’s a disease right now of the unvaccinated when you’re getting to my level, when you’re getting to the ICU. And so the most important thing people can do is get vaccinated and get boosted. For omicron, just having the first two doses is somewhat protective, it looks like, but that third dose is actually really immunologically interesting. It’s more than a booster. It actually seems that having that third dose after a time frame helps create a much more mature immune system, with a much more robust response against omicron. So all I can do is just encourage everyone to get vaccinated. It’s kind of the most important thing you can do to avoid seeing me, and no one wants to see the ICU doctor.

Kevin Pho: For those who do recover from COVID, do you see any regret from patients?

Erika Maria Moseson: Yes. I would say the vast majority of people, as they’re coming into the ICU, are kind of sheepish a lot of the time, and saying, “Yeah, I kind of wish I got vaccinated,” or, “I was just waiting.” Very few people, although there have been some. I’ve had people screaming at me that I’m lying to them, that they have COVID. But for the most part, it’s really sad when they ask, “Can I get the vaccine now?” when they’re already coming to the ICU with COVID, where it’s way too late.

But most people recognize, “Gosh, this really is serious.” And maybe they’ve been misled on Facebook, or there are all sorts of people trying to hustle and sell whatever product they have and make money on sowing vaccine misinformation. But most people, I would say, who come in kind of wish they’d gotten vaccinated. Not everybody, but a lot of people, even recovering, talk about, “OK, when can I get my vaccine? I don’t want to go through this again.”

Kevin Pho: All right, so let’s transition. The article that you recently wrote is about our air in schools, which is a very, very relevant topic that I’m certainly hearing about in my own daughter’s schools. It’s titled “Clearing the air our kids share: a prescription for healthy schools.” Now, for those who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Erika Maria Moseson: Yeah, absolutely. Going over the summer, I have three young kids. At the time, they were unvaccinated, and so we were just trying to think of all the things that could help prevent transmission in schools. For most of the summer, I was advocating fairly strongly that we maintain a mask mandate, and then really focusing on, OK, well, once the kids are sharing air and they’re wearing masks, when we’re starting to see the explosive rise of delta, and realizing that despite that there may still be significant transmission risk, what else can be done?

And so Johns Hopkins and the CDC and multiple organizations had really looked at what the evidence shows, and had put together guidelines for what can be done. What you really want to be doing is diluting the virus from the air, and the best way to do that is both with ensuring there’s good ventilation, whether in your HVAC system, if you’ve got a centralized HVAC system, cranking that fan up. You really are trying to shoot for six air changes an hour. And then in places that don’t have a central system, making sure there are windows open with a really good cross breeze, and also adding HEPA filtration into the classroom, where you are actually pulling virus out of the air, particulate matter out of the air, and trying to circulate that and capture it on a fibrous filter.

There’s also a lot of concern about the flood of funding that went out to schools to help them with COVID, and the ways it may have been potentially misdirected at technology that we’re not quite certain of yet. There are a lot of, I’m sure, very well-meaning companies out there advocating for putting chemicals into the air to try to clear it or kill the virus. So everything from nebulizing or putting hydrogen peroxide out into the air the kids are breathing. There’s a lot of talk of foggers. There’s a lot of talk of ionizing technology, with claims that these ions are going to make the viral particles glom together and they’ll fall to the ground. And really, the more I’ve explored that with experts, we really don’t have the data to support these additive technologies in terms of health benefits.

So it’s kind of one of those things where maybe they work, but if they do, it’s probably not healthy for your kids to be breathing them, because the field of pulmonary medicine is littered with stuff that we thought was safe to breathe and turns out to cause disease. So it’s either they do work, but you probably don’t want your kids breathing it, or maybe they don’t work. And there are some studies of some of these commercially available in-duct ionizer systems or hydrogen peroxide systems that suggest that when you’re actually looking at building scales and the complexity of the built environment, they really may not be doing anything, in which case you’re only accepting the risk of the harm and not really the benefit.

So it’s something that I didn’t think about a lot in med school, HVAC systems and air filter technology and the way our buildings are built, but it is actually something that’s very important to human health.

Kevin Pho: When it comes to HEPA filters, I’ve seen so many different types being sold to our schools. Any specific type? Is this something that you just buy on Amazon? What do schools have to look out for when they’re purchasing or considering a HEPA filter?

Erika Maria Moseson: So honestly, with HEPA filters, the thing to look for is to make sure it’s a true HEPA filter, right? The hard part is this is completely unregulated. The only thing: California has attempted to at least show whether or not something’s emitting ozone, because ozone is completely toxic to human health, and some of these older technologies and ionizers would actually emit ozone that can really be toxic. So there’s really not that much regulation.

What you want to be looking for are HEPA filters that are certified. They have to go through a testing process to show that they reduce particulates below 2.3 microns in a very efficient way. So I would be looking for things that say HEPA filters. And then the most important thing is you want to look for the CADR, which is the clean air delivery rate, which basically is the size of the air that that filter can handle, and it’ll tell you how many air changes you can expect for a room that size.

So really, just buying a little teensy tiny one that’s designed for a 100-square-foot room and expecting it to really clear the air of a 600-square-foot classroom, or to be put in a gym, doesn’t really work. They’re not magic. But they are additive, right? So if you get two in a row, you could add their CADRs together to try to clear that space. So really just looking for something that’s taking something out of the air, that’s pulling the particles out, and then making sure it’s appropriate for the size of that room is the way to go.

But I don’t endorse any specific devices, nor does the CDC or the Johns Hopkins Center for Biosecurity, who really authored one of the more expert reports on this topic. There are a lot of different manufacturers, but as long as you’re looking for a HEPA filter that’s really pulling things out of the air and not adding things into it, I think schools are in.

Kevin Pho: So correct me if I’m wrong. From what I’m hearing, if schools were to spend money to, quote unquote, upgrade their air filtration system, they should be looking to upgrade their HVAC system and purchase true HEPA filters. Are those the only two things that you feel are recommended?

Erika Maria Moseson: Well, so there are a couple of things. More modern buildings have a full centralized HVAC system. If they can, they should contract with their HVAC professional to get to a MERV 13 filter or higher. That’s basically putting in that HEPA-level filtration for a whole building. And then if they can work to try to be getting that six air changes an hour through their centralized system, that’s great, and you probably don’t need portable HEPA filters in addition. If they can’t, then it may make sense to add in a HEPA filter or two, if you can’t quite get there with your central HVAC system. And that just is more of a power issue and a how-much-strain-can-the-system-handle question, and that’s beyond my scope. That’s more for the engineers.

And then the other thing is ultraviolet germicidal radiation does work, but it’s very expensive, and those bulbs have to be changed every six months. Those are pretty sophisticated ways of killing virus and everything, but those can be very prohibitively expensive, and that’s something that you have to put up into the central system and make sure that no one can see it, right? Because obviously, if it’s UV lights that you’re seeing, that’s not good for you. And then people will market all sorts of things, like little UV wands that you wave around, and you don’t want to get derailed into very expensive UV technology potentially if you’ve got a fixed budget. So I think it definitely works, and it’s recommended, and a lot of places will use that to clear the air of infectious agents, but it can just be a lot more cost-prohibitive depending on the school’s budget.

Kevin Pho: So from your experience, how many schools do you estimate have satisfactory air filtration systems, based on what you’ve told me?

Erika Maria Moseson: I honestly don’t know. It’s been so interesting, and it’s been interesting to have parents reach out to me, right? So, putting that first episode out about the air kids share, with an expert from the Center for Biosecurity, Paula Olsiewski, I then had people reaching out, sending me the email sketches of what their school had installed in the district. And it was wild. There is a lot of this ionizing technology out there, and it looks good. You go to their websites, and it looks pretty spiffy. They give you these chamber studies where they show these viral particles falling. And granted, it’s not usually tested on the actual virus. It’s generally tested on a phage or a similar type of virus, and they’re usually small chamber studies, really not studied at the building-scale level.

So it’s interesting. Some schools have actually engaged in lawsuits after some studies came out showing that these may not work at the whole-system level. Some schools are actually going after these companies, who are in turn turning around and suing the researchers. So it’s getting a little conflicting. And I’m sure a lot of people were very well-meaning and said, “Oh, well, hydrogen peroxide kills virus. Let’s just throw it into the air,” without thinking from the medical side. Well, would you say, “Hey, I’ve just pumped a bunch of hydrogen peroxide into this air. Send your child in there to breathe it”? I wouldn’t. Granted, I’m a lung doctor, but I think a lot of people wouldn’t want to do that either.

So again, it goes back to either that other technology does what it says it does, in which case it’s probably not healthy for our kids to breathe it, or it doesn’t really do that much, in which case it was kind of a waste of money, and we could have spent it better on HEPA filters.

Kevin Pho: Can you give us an idea of the scale of the cost if a school were to upgrade their filtration system? Are we talking about thousands of dollars? Are we talking about tens of thousands, hundreds of thousands? Just give us an idea about the potential costs, and whether this is prohibitive for many schools.

Erika Maria Moseson: Yeah, well, the nice thing is there was a lot of funding with the CARES Act for COVID upgrades, specifically for air-cleaning technology, which I think is kind of why there is a flooding of the market with some of these things that may not work, because where there is funding, people will find it. And I think it depends. I’m sure upgrading an entire HVAC system is very expensive, and it probably depends on the type of school and where you’re at. But I do think there are things that can fit each budget.

So you can get a 400-square-foot HEPA filter cleaning, and that’s pretty good. I have one for my house that’s in the $200 range, right? And so granted, you scale that across a bunch of classrooms. But even just simple things, like thinking of the ventilation, the dilution element of it, where you open the window, introduce a cross breeze, and then have some more HEPA filters, and that would be at the lower cost. And there are other options where you strap a MERV 13 to a box fan, and that’s 50 bucks, which got scaled up a lot in the wildfires, and which honestly works in a similar way.

So I think, compared to the scale of a lot of the other expenditures schools make, I hope that this would be a reasonable investment. And more importantly, the CDC’s done some modeling that shows with masking and a couple of HEPA filters, you can drop the potential viral load in a room by something like 90 percent. So it’s pretty effective. And when you think of the cost of each extra spread of COVID and people spending time in the ICU, I would hope that communities at the state level, county level, and federal level view this as an investment that’s worth it.

Kevin Pho: Can you give us a sense of the data? So you did mention that things like HEPA filters and masking can decrease viral load, but in terms of real-world scenarios, is there any data suggesting a decreased relative risk reduction if we properly install HEPA filters in a school?

Erika Maria Moseson: Well, so I think it depends. I honestly hope that people study this going forward this year, because I actually think we have a bunch of observational cohort studies ongoing across a bunch of different schools in America. The data for HEPA filters, for example, looking at particulate matter. A lot of the time with COVID, there’s been this concern about COVID traveling with particulate matter, or areas with these smaller particles being a problem for COVID. So when they’ve looked at things like HEPA filters in wildfire scenarios, where they do these pretty good sham trials, where they’ll have one in the corner of a house that’s running and one that’s not running, you can actually see the decrease in the particles of concern in the ones where it’s actually running, and then also decreased respiratory events and everything, especially for vulnerable populations.

For COVID specifically, I’m not aware of studies that have come out yet, especially for schools, since a lot of people were out of school. But I’m hoping that that will be studied, because I think this is something we need going forward, because a lot of times, doing things to decrease particulate matter is going to be important not just during COVID but obviously during wildfire season, or for urban schools heavily affected by air pollution, or for rural schools heavily affected by wildfires.

So investing in clean air in COVID times, especially if you’re doing subtractive technology like HEPA technology to reduce particulate matter, is going to also pay off during wildfires and air pollution and all the allergies, pollen. We have increasing pollen burden as the climate warms. So I think it’s kind of one of the things that, if you invest in the right technology now, I think it pays off in the long term.

Kevin Pho: We’re talking to Erika Moseson. She is a pulmonary critical care physician, and she wrote the KevinMD article “Clearing the air our kids share: a prescription for healthy schools.” Erika, if I’m a school administrator, I think I’ve heard some of the messages that you said, but what are some of the top take-home messages that you want to give to school administrators out there when it comes to clearing the air in schools?

Erika Maria Moseson: Well, I like a phrase that I’ve heard called the four Ds. So thinking about density, right? So decreasing the number of people in a space. Thinking about distance, keeping the space between them. Thinking about the dilution of the air, right? So both not having the mask putting things out, and then also using the HEPA filters and open windows and everything to clear the air. And then duration, right? So trying to not have people together for too long, or trying to get them outside if they’re going to need to be together for a while. So I kind of think those four Ds are helpful.

And then investing in technology that is recommended by public health experts. The Johns Hopkins Bloomberg School of Public Health has put together an excellent document specifically for administrators that I like, that actually has punchline, take-home, simple messages, and it’s not too technical. And so I think looking to those kinds of resources, and not necessarily trusting the super friendly and well-meaning salesperson who wanders by promising magical ions that will pull COVID from the air.

Kevin Pho: Erika, thank you once again for coming on the show and sharing your time and insight.

Erika Maria Moseson: All right, thank you very much.

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