Healthy schools and workplaces: What the post-COVID-19 state should look like
MANILA, Philippines – At some point, we will experience COVID-19 as an endemic disease in the Philippines. If we do the necessary public health work, we will be able to live with the virus as a society.
But once we achieve endemicity, can we finally sit still and call it a day? Not quite it seems.
The reality is that SARSCOV2 is likely to remain ever-present in our population, just like the flu virus. We will have to ultimately change our behavior and our environment in order to manage the risks of living with COVID-19 and of thriving as a society.
The risk management approach
Once COVID-19 endemicity has been achieved, how do we prevent future epidemics or pandemics? The answer lies in individual behavior changes and environmental adjustments. Identifying residual risks and mitigating them will be the work we have to do in the years to come. However, this will allow us not just to prevent future COVID-19 outbreaks but perhaps other diseases as well.
General principle: Identifying residual risks
First, we need to assess the risks involved in dealing with COVID-19. We can assess risk through the same framework and formula used in disaster risk reduction. That is: Risk = Hazard x Exposure x Vulnerabilities.
Hazard in this case pertains to SARSCOV2. However, there is very little that can be done to prevent viral evolution and the production of new variants. True, we can try to prevent transmission, but as we have seen in the past two years, that is a near-impossible thing to do. Adding to this difficulty is the fact that SARSCOV2 is spreading and evolving even among wildlife. So the focus will have to be on reducing our exposure to SARSCOV2 and on reducing the vulnerability of the elderly, of people with comorbidities, and that of the immunocompromised.
In a post-pandemic setting, we can continue to reduce our exposure to the airborne virus through non-pharmaceutical interventions, such as using high-grade face masks, avoiding crowds (that is, situations where social distancing is not possible), and ensuring good ventilation. In fact, doing these practices also lessens our risk for other airborne respiratory diseases. This is evidenced by the reduction of the deaths due to pneumonia and pulmonary tuberculosis during the pandemic.
A simple rule of thumb we can follow is the “3 out of 4 rule.” The rule states that if we observe three of the following interventions, we can forgo the fourth: vaccination, masking, distancing, and ventilation. For example: a vaccinated individual need not wear a mask, if good ventilation and proper social distancing is maintained. This is a variation of the 2 out of 3 rule of Dr. Lindsey Marr, an environmental engineer specializing in viral airborne transmission.
We can reduce our vulnerabilities by:
- Improving individual lifestyles through proper nutrition, physical activity, adequate sleep, and stress management
- Controlling chronic conditions, like diabetes and hypertension
- Being up-to-date on not just our COVID-19 shots, but also our pneumonia and flu vaccinations. Annual COVID vaccine boosting could be a possibility in the future. We also need to improve our ability to understand and manage the chronic effects of long COVID-19.
Using this risk assessment framework, we can now discuss how to design our spaces for the post-COVID era.
The healthy settings approach
Because people live in a variety of contexts and environments, we have to consider COVID-19 risk across a variety of settings. The healthy settings approach can guide us in our effort to live with COVID-19 safely.
The World Health Organization has defined a healthy setting as “the place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and wellbeing.” In an endemic situation, we should bolster risk mitigation of COVID-19 by redesigning schools and workplaces. By doing this, we mitigate not only COVID-19 risks but risks from other airborne respiratory diseases as well.
Healthy schools
Reopening schools safely continues to be a difficult problem. Unfortunately, there isn’t a one-size-fits-all approach when it comes to doing that. Children will have different needs as they age and develop. Schools will have different contexts and resources.
If we have learned one thing over the past two years, it is that online learning is insufficient for the proper cognitive and social development of children. This is particularly true when it comes to reading and literacy. Without these basic skills, children will be unable to learn more advanced content. In the United States, there is a growing problem of declining performance in reading skills since the pandemic began. It is very likely that a similar phenomenon is happening here in the Philippines.
When it comes to COVID-19, student learning, and children, there are still a lot we do not know. For example: Do face masks inhibit speech and cause developmental delays? Will testing children regularly do more good than harm? What non-pharmaceutical interventions will be applicable, given physical school attendance? Do children need to be vaccinated to attend school safely? With all these unknowns concerning children and COVID-19, decisions will have to be made based on subjective assessments of the level of risks acceptable to parents. They need to be confident to send their kids back to school; children, likewise, need to feel safe as well.
Parents would be at ease to send their kids to school if they perceive that the risk of COVID-19 exposure to their children is low. Several steps can be done:
- First, parents should be given information on the COVID hospitalization rates in their community.
- Second, antigen testing should be accessible to schools whenever necessary.
- Third, classrooms should be well-ventilated and monitored using carbon dioxide sensors.
- Fourth, face masks should be necessary and required whenever community transmission is high. However, the wearing of face masks need to be balanced with the ability of students to learn.
- Fifth, access to clean water and sanitation will also be necessary. School, after all, is the place where we learn to wash our hands.
As the Omicron variant predominates around the world, the rate of pediatric COVID-19 has increased worldwide. In the United States, it has been studied that around 75% of children and adolescents now have evidence of past COVID-19 infection.
Subsequently, a condition called Multi-Inflammatory Syndrome in COVID-19 (MIS-C) has been a cause for concern, especially in children aged 5 to 11 years old. It has been increasing in occurrence as more children get infected with COVID1-9. But getting children vaccinated has been met with much hesitancy not just locally but around the world as well. Parents are hesitant to have their children vaccinated despite the more apparent risk of COVID-19 and its complication of MIS-C.
In an endemic COVID-19 state, there must be clear guidance and acceptance of COVID-19 vaccines even for the pediatric population. Full approval by the Food and Drug Administration will result in higher vaccine confidence among parents. When a majority of children have been vaccinated, mandating schools to enforce vaccinations will ensure that schools remain as safe as possible and individual vulnerabilities are mitigated within the school setting.
Vaccine mandates in schools amidst an endemic disease is not unheard of. For example, we vaccinate against the poliovirus, which has resulted in tremendous success in preventing disastrous health outcomes.
In an endemic COVID-19, schools will have to make up for the learning loss incurred during the pandemic. This loss will undoubtedly bring forth social and mental health problems typically associated with poor learning performance. Public and private schools will have to bolster their capacities to provide aid to students with these learning losses. Schools will have to determine how much damage the pandemic has done to their students’ performances through standardized assessments. Curriculums and expectations need to be flexible and student-specific. Remedial learning should be provided for students who are behind in their learning. These can be done through tutoring and small classroom engagements. Improving teacher-to-student ratios in school will also ensure that students will get the proper attention and support they need from their educators.
Healthy workplaces
If we are to live with endemic COVID-19, we will have to keep our workplaces safe. Workers need to feel safe in order to be productive. Otherwise, no one would want to show up for work. The challenge of creating healthy workplaces is the need to identify and quantify the variety of risks and hazards involved across different occupational environments.
Workers who need to physically attend work must be given just compensation (that is, hazard pay and paid sick leaves) and be provided the necessary personal protective equipment. Growing establishments and industries should consider investing in more open work spaces. This is particularly true for blue-collar workers and those in the service industry. Work-from-home or hybrid work should be done whenever possible and workers should be provided with access to fast internet connectivity.
Current occupational safety and health standards have been created in the Philippines. However, there has been difficulty in implementing them.
An example of this is ventilation in workspaces. Ensuring sound ventilation would effectively lower the risk of exposure not only to COVID-19 but also of other airborne diseases, such as pulmonary tuberculosis. It may come at high initial cost to employers and establishments, but improving ventilation and installing high grade filters (if ventilation isn’t possible) will pay for itself in the long run. A simple and effective way to objectively measure ventilation status is the use of low-cost CO2 monitors. These should be installed around the workplace to keep workers at ease.
The risks from commuting to work should also be mitigated. Improving mass transportation and easing traffic congestion, which shortens travel time to work, could lessen exposure of workers to others in the community.
Ensuring that workers are eating and exercising right would reduce vulnerabilities to COVID-19. These vulnerabilities, like obesity and diabetes, are particularly prevalent among sedentary white-collar workers. These are also the workers who will benefit the most from COVID vaccination. With continuing viral evolution, seasonal COVID-19 vaccinations may be necessary.
Preventing the next pandemic
Overall, maintaining an endemic COVID-19 will be the long term work of public health for the years to come. But we cannot return to the old normal way of doing things. An endemic state COVID-19 may bring some respite from surges and the subsequent lockdowns, but the possibility of a new epidemic and pandemic is always on the horizon. Beyond coronaviruses, there are many more viruses out there that can bring about the next pandemic.
Ultimately, we can’t just return to getting Philippine society up and running again. We have to make the necessary changes to be better. The COVID-19 pandemic was able to uncover many vulnerabilities in our public health system. Nothing short of transformative change is needed if we are to succeed in properly surviving or preventing another pandemic. Government will have its role to play to make these changes, but ultimately we as Filipinos will have to constantly work together until we get it right. – Rappler.com
John Q. Wong, MD, MSc, and Carlo Yao, MD, MBA, are from EpiMetrics Inc., a public health research institution focused on the achievement of health equity through rigorous and creative conception, execution, translation, and communication of health systems and policy research.
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