A Rational Reopening Guide

BY MEGAN MANSELL

A framework for operating any facility or business during COVID

The United States already has a body of law that requires making accommodations for persons with disabilities; if we start from the premise that Americans should be able to determine the level of risk they’re willing to take, all of those concepts can be extended to provide accommodations to anyone who is concerned about exposure to COVID, whether because they are vulnerable or because they live with someone who is vulnerable.

The first step is to ask everyone whether or not they consider themselves immunocompromised (IC). This can include people who themselves are immunocompromised or who live with someone who is immunocompromised. Allowing people to identify whether or not they consider themselves immunocompromised allows us to create reasonable accommodations for accessing the public sector. Some people cannot mask, and others prefer not to, but we can still allow them to safely access shared spaces if we know how many individuals are truly in need of accommodation.

Those who cannot or prefer not to mask should be free to assess their own risk, especially for a contagion with a 99.6% recovery rate.

If we ask everyone to identify the population they belong to, it all falls into place.

Residential care facilities 

Successful containment protocols for nursing homes and developmental care facilities depend on access to rapid, accurate testing. The only people generally coming and going are workers, family, and vendors, and IC populations can be protected by testing these people. If the rapid test indicates that a person is not contagious, he or she can enter a vulnerable population bubble with greater confidence in avoiding transmission. This practice is called osmotic immigration.  

Alternatively, a person who wishes to enter the bubble of the facility can undergo an honest quarantine period of 8 days without contact (this is the current CDC guideline, but others have recommended up to 14 days), and the vulnerable who have been in isolation can have visitors safely and without masks, providing human contact and normalcy after harrowing months all alone. This is also a good measure to implement for someone who will be a new addition to the population, as rapid tests only indicate transmissibility upon testing. Those exposed but not yet contagious would not be flagged positive on a rapid test, and this would be a better practice for decreasing likelihood of transmission. 

The emergency operations site protocol for all residential care facilities should include a lockdown containment protocol that designates two or more alternating teams that operate in shifts in the event of a quarantine-type emergency. High-level and support positions must be available to the facility at all times since the populations they serve cannot be relied upon for self-sufficiency. The members of these teams should be selected primarily from those who have the fewest familial responsibilities and the greatest ability to cover site-wide roles.

These populations demonstrate an increased likelihood of fecal/oral transmission; once contagion is within a given bubble, spread is very difficult to control, as there are multiple methods of transmission to control.  Therefore, these vulnerable populations should get our best personal protective equipment (PPE) and most stringent oversight, yet protocols still must address personal choice and representation of risk determined by families and those who hold Power of Attorney for residents: if people do not want to live in isolation or do not want the loved ones they legally represent undergoing stringent and isolating protocols, there should be facilities that offer restricted access and others that allow people to live freely as before. 

Schools

Students and teachers who select the IC option can be placed in bubble isolates, which are groups that agree to specific quarantine periods and a code of conduct. These groups, for example, might include parents who work at home, siblings who are also in bubble isolates, and families that agree to get delivery and use true baseline PPE when around others.

There would be no guarantees, but it gives safer options to IC employees and families who long for any normal, new or not. This is an allowable designation under current special education accommodations law. Testing or quarantine would be required for a new person to enter the bubble isolate. The removal of penalization for truancy is also a factor in protecting school populations, as people need time to get well and ensure a household is not contagious before reentering settings like schools and childcare facilities.

For IC employees wanting some non-remote access, they can either elect to be part of a bubble isolate, train others for testing and intervention, be responsible for IEP/ELL implementation monitoring, provide outdoor extracurricular activities, or teach lecture-style for higher-level teachers needing physical separation from students.  

Severely IC teachers deemed irreplaceable could give virtual lessons to a class remotely, with an aide supervising the physical class.  

School buses should not be driven by masked drivers, as tampering with oxygen levels of vehicle operators creates safety and liability concerns.

Buses should be sanitized after each route, but air is circulated and movement around the interior is unavoidable when servicing multiple stops. If concerned about the safety of children, we should begin by installing seatbelts, not masking healthy children.

Most school systems have separate transportation for special education populations and could provide restricted ride access for higher-need IC students participating in bubble isolates (along with others within their bubbles) who have no other methods of transportation. Personal transportation is the safest method of limiting outside contact. This special type of transportation service would be a wise place to use rapid testing before driver shifts, and the position should be filled by a low-contact individual if this information is able to be determined.

Retail

Stores with a majority of employees who want to be maskless can open up for extended mask-optional hours, with IC-identifying employees working mask-mandatory shifts in appropriate PPE during special hours. Proper sanitation protocols between use of shared spaces can include UV sanitizing light equipment that quickly sanitizes large spaces, air scrubbing additions to HVAC systems, and sanitation of shared surfaces. IC individuals who cannot mask should only work remotely unless they are willing to accept personal risk and work during the mask-mandatory or mask-optional shifts. 

Grocery stores and other essential goods and services should be mostly open to the general public without restrictions, with special hours for the immunocompromised. The earlier their access hours, the better, as this allows for overnight air exchanges between the hours when maskless and IC persons access the space. 

Churches, theaters, sports venues

Houses of worship can have services specifically designated for vulnerable populations, or they can continue to serve these congregants digitally. 

Movie theaters can schedule showtimes for IC access. It would be best for them to be earlier shows, to allow time to sanitize the air and surfaces after use by non-IC persons.

Large events at places such as sports stadiums can be segregated into mask-optional and mask-mandatory sections, separated by space to avoid commingling. 

Restaurants, bars, fitness centers

Restaurants are places where a lot of contact with open oral cavities takes place. It is an unreasonable accommodation to expect others to cover their mouths between bites. Outdoor seating, distanced tables for IC individuals, and non-peak-hour shifts for IC staff are reasonable. 

Bars, clubs, and fitness centers can designate special hours to people who prefer masks if they so choose, but active respiration without an airflow barrier while running and dancing should be seen as normal for these settings.

Transportation

Car services should not be seen as sterile environments; masking drivers lowers oxygen saturation rates and impairs driving, potentially causing accidents that can maim or kill.  

Trains can be segregated into mask-mandatory and mask-optional compartments, with separate queueing areas. 

Buses can designate specific route times for IC access or segregated seating for those wishing to increase distance from others, but airflow is circulated and public transport is generally an unclean environment. Some cities offer separate disability transportation services, and the use of these would be best practice for vulnerable populations. Drivers should not be wearing oxygen-restricting apparatuses, including masks.

Elevators and public restrooms

Enclosed spaces such as elevators and public restrooms share recycled air. Elevators are appropriate spaces for IC individuals to use proper PPE if needed, as close proximity for extended periods would naturally increase risk if you are among infected persons. However, due to the likelihood of fecal/oral transmissibility, mask usage in public restrooms should be seen as an increased risk for mask contamination due to airborne spray from flushing and hand dryers.

Medical settings

Medical settings should segregate the ill and injured as they are able. Wellness visits should not be in shared air spaces with sick visits. All medical environments should be assumed to be our most likely places for potential spread of any virus.  

Miscellaneous topics

Private homes and businesses should operate based on owner preference, not mandate. However, businesses still must offer reasonable accommodation for maskless populations, as all have the right to reasonable accommodation under ADA. Delivery and drive-up are reasonable accommodations – refusal outright is discriminatory unless posing a direct threat, such as proximity required during hair cuts or similar settings. It should then be up to provider consent. 

Housing with shared HVAC systems should install HEPA filtration and take additional sanitation measures.

Humans should not be restricted by requirements regarding proximity to others or ability to touch, interact, or assemble. Free will and risk assessment are part of every good and bad decision we have ever made. 

Multilingual services were generally not provided during this pandemic. We must be communicating clearly with all members of our communities so they may best protect themselves and their families during a crisis.

Masks

• Cloth masks have no production control variables that allow an estimation of their efficacy. They should not be touted as safe protection from COVID-19.
• Surgical masks are porous by design and intended for catching blood-borne spray in close proximity in surgical and dental settings. They do not withstand plosive force, they gap on their sides, and they do not protect the wearer or others from COVID-19-size particulates. 
• N95 masks are the baseline minimum PPE requirement for COVID-19-size particulates. COVID is a suradically-behaving particulate that does not respond predictably to gravity. The OSHA requirement for personal protection in known contagion is new N95 grade or higher respirators plus eye protection. In a workplace, this requires an OSHA-certified fit test.
• Even higher-grade respirators require caution. Many fibers and a wide range of contaminants have been found in tests of new masks straight out of packages. Extended use of these masks means these fibers and particulates are ending up in the respiratory tract. 

More on OSHA: It was not a violation to require a face covering in some relevant settings pre-COVID, but it is an OSHA violation when people think it is being worn for personal protection, which many blindly do when reckless mandates are issued by governments. It is an OSHA and furthermore a human rights violation to require someone to wear a face covering deemed unfit for use against a given particulate size. Cloth and surgical masks do not filter COVID and do not meet OSHA standards as PPE for COVID-size contagion. 

Testing

The COVID crisis cannot come to a close until we address a critical failed element in containment: test administrators are not using exhale-filtering PPE at test sites and when among vulnerable populations.

COVID, at .06-1.4 microns, is pressurized on exhale via 4+ micron holes in masks and sent forcefully airborne in a concentrated stream during a plosive-force-generating activity (sneeze, cough, or scream). This radically-behaving particulate does not respond to gravity predictably, as larger droplets do.

This widespread error turns test sites into transmission points, as the environment and testing materials are exposed by contagious parties. Contaminated swabs are then placed directly into nasal mucosa. This can account for some of the asymptomatic and presymptomatic cases, as contaminated swabs can be the first point of contagion. Tests administrators are those most likely to come into contact with contagion, and tests administered in contaminated environments are invalid.

Further justification for totally scrapping and starting over on our testing protocols is a lack of nationalized standards for PCR cycle thresholds used to determine a positive test. Every cycle doubles the viral matter; studies have shown that the cut-off for the presence of live viral (infectious) COVID-19 is 34 cycles, but some labs are using a threshold as high as 41. 

These flaws can be corrected by using exhale-line-filtering PPE or encouraging self-administration in isolation with swabs from sterile packaging or with materials provided by the individual (such as a Q-tip or tissue), submitted in a sealed container and sent to a clean room lab for processing. If a lab can’t guarantee that the tests themselves aren’t the source of contagion, it cannot assert testing validity, which is essential when you consider that the lives of some of our vulnerable friends and relatives are truly at stake.

Conclusion

In the 30 years that we have had HIV, we have had no vaccine and no condom mandate, yet contracting HIV was once a death sentence. Latex condoms with 98% efficacy are recommended because they have assertible, tested efficacy percentages. Recommending cloth and surgical masks as effective with COVID is no better than recommending condoms full of holes when having relations with HIV-positive partners. If a much deadlier outbreak comes along and we do not first correct widespread misinformation on mask efficacy based on particulate size and type, we will be no better prepared as a nation than we were throughout the COVID pandemic.

Megan Mansell is a former district education director over special populations integration, serving students who are profoundly disabled, immunocompromised, undocumented, autistic, and behaviorally challenged; she also has a background in hazardous environs PPE applications. She is experienced in writing and monitoring protocol implementation for immunocompromised public sector access under full ADA/OSHA/IDEA compliance. She can be reached at MeganKristenMansell@Gmail.com.