The death of hundreds of children from Covid-19 in Indonesia in recent weeks should serve as yet another dire warning that children are at risk of severe illness and death from new variants. More than 800 children in Indonesia have died from the virus since the pandemic began, but the large majority of those deaths have occurred in the last month as Indonesia has become the new epicenter of the pandemic. More than 150 children died from Covid-19 during the week of July 12. 

The Delta variant is largely responsible for rising cases (particularly in unvaccinated populations) across the world including a steep incline in the US. The variant is highly contagious and a recent study from China shows that those infected with the Delta strain can carry up to 1,000 times more virus in their nasal passages. It is in this high-risk environment that we are sending our children back to classrooms, unvaccinated and highly vulnerable. Yet there is one critical action we can take to protect our children as they return to school; well-ventilated indoor spaces. 

The body of scientific evidence pointing to airborne transmission as the main route by which SARS-CoV-2 spreads is now overwhelming. In outbreaks and super spreader events, there are often three common elements; an indoor space, an absence of masks, and a low level of ventilation. We need to re-evaluate the perspective that the spread of airborne pathogens in indoor spaces (whether they cause the common cold or Covid-19) should be considered to be an inevitable part of daily life. Aerosol scientists and researchers have long advocated for this, but a lack of research into and long-held misunderstandings about airborne transmission of pathogens has contributed to a lack of recognition for this important issue.  

For decades, governments worldwide have invested heavily in food safety, sanitation, and drinking water quality for public health purposes. Food and waterborne disease have largely been eliminated in developed countries, due to a combination of research, legislation, the development of authoritative bodies, and infrastructure funding. It is time we give the same priority to achieving clean, pathogen-free air in buildings and indoor public spaces.           

Many critics of such a policy will cite significant costs as a barrier, However, the economic losses of even an average flu season cost the United States $11.2 billion, primarily due to reductions in productivity and absenteeism. The total cost of the Covid-19 pandemic was estimated at more than $16 trillion, or approximately 90% of the annual gross domestic product of the US in October 2020. As the pandemic rages on these costs will only grow. Beyond the direct financial costs, the trauma and turmoil inflicted by the pandemic make it clear that taking these preventative steps is not only economically sound but also the most ethical option.         

The goal should be the explicit inclusion of protection against indoor air hazards (including airborne infection control) in the statements of purpose and definitions of all relevant building design and engineering standards, regulations, and codes. Comprehensive ventilation standards must be developed by professional engineering bodies. New approaches must be developed to encourage the implementation of standards, one option is implementing “ventilation certificates” similar to food hygiene certification for restaurants. Over time, all new buildings would ideally be designed to ensure good indoor air quality, while existing buildings will be retrofitted. In a publication for the journal Science, a group of experts including Aerosol Physicist, Lida Morawska argued that the recently published WHO Ventilation Roadmap was “an important step but falls short of recognizing the hazard of airborne respiratory infection transmission and, in turn, the necessity of risk control”. 

A national fund will also need to be established, to enable the rollout of indoor environment modernization measures addressing both immediate emergencies, such as Covid-19, as well as a long-term transition process.

Controlling airborne pathogens does present challenges that controlling food and waterborne disease do not. Air as a contagion medium is nebulous, widespread, not owned by any entity, and uncontained. Furthermore, buildings and their airflows are complicated, and measurement methods for such studies are complex and not generally standardized. The rate of viral emission also differs depending on the physiology of the respiratory tract, the stage of the disease, and the type of respiratory activity such as speaking, singing, or heavy breathing during exercise. For these reasons, infection-focused ventilation rates must be risk-based rather than absolute.

This is not to say every indoor space needs to become a biosafety facility, but a building should be designed and operated according to its purpose and the activities conducted there, so that airborne infection risk is maintained below an acceptable level. Specialized training should also be provided to building operators and owners.  

With children still not eligible for vaccination, our first priority should be on ensuring pathogen-free air in classrooms and school buildings. All states should be following the lead of Virginia which is investing $500 million to improve ventilation and air quality in public schools. Not only will we be protecting our children from a deadly virus, but there are also postive long-term impacts. Children show improved cognitive performance in better-ventilated areas and they also report fewer instances of illness-related absenteeism.

Like many other issues of public health, the Covid-19 pandemic has highlighted the desperate need to prioritize air quality in indoor spaces and the government’s role in regulating this issue.  According to the EPA, Americans, on average, spend approximately 90 percent of their time indoors. Just as we expect clean water to come out of the tap and we expect sanitary food preparation, we should also expect to breathe clean air.