‘In those school-rooms where ventilation is imperfect and the air impure, six sevenths of the money expended to educate a child is wasted.’ ❂ The Ventilation and Warming of School Buildings (1887) By Gilbert B. Morrison Published by D. Appleton and Company, New York. 1887. Accessed 10 Apr 2024 Preface (p.xxii) ❦ ‘I am fully convinced that people are prematurely dying by thousands simply from a lack of correct and positive convictions concerning impure air; for, when the true nature of a danger is fully appreciated, the requisite means to avert it will generally be found.’ ❂ Chapter II: The Effects Of Breathing Impure Air (pp.20-23) ❦ ‘Impure air is also believed by the best authorities to be one of the principal causes of epidemics. Dr. Carpenter, than whom there is no abler authority, says: “It is impossible for anyone who carefully examines the evidence to hesitate for a moment in the conclusion that the fatality of epidemics is almost invariably in precise proportion to the degree in which an impure atmosphere has been habitually respired.” The Board of Health of New York conclude that forty per cent of all deaths are caused by breathing impure air. In view of such alarming facts, this same board declares: “Viewing the causes of preventable diseases, and their fatal results, we unhesitatingly state that the first sanitary want in New York and Brooklyn is ventilation .” Direct experiment proves that the air in our school-rooms is impure in almost all cases, and in a majority of them to a degree far beyond the danger line. In view of these facts, and the results as proved by the authorities above cited, why is it regarded by the public with such indifference? When a school-house is blown down by a hurricane, killing and maiming a score of children, it is justly regarded as a great calamity; a vacation is given to quiet the excited fears of parents and children; investigating committees are appointed to locate the responsibility, and the faces of the whole populace are blanched with apprehension. Why is this? Why does the intelligent parent send his child to a school-room poorly ventilated and crowded with children, some of whom are breathing into a stagnant air the germs of disease and death, while others, from unwashed bodies, are delivering into it their deadly emanations, and all without a protest on the part of those even who provide proper hygienic conditions at home? It is because the effects of the one are immediate, occupy little time, the number killed can be actually counted, and the exact magnitude of the calamity estimated all at once. In the other case the process is slower, but of far greater extent; the actual results are by the general public less definitely known, and custom and attention to other matters divert the attention, and the deadly destruction of the innocents by impure air goes on silently, constantly, and powerfully. While noisy demonstrations like that of the cyclone attract attention, and inspire fear and terror, it is in the silent forces that the danger lies. Nature’s most destructive forces, as well as her strongest constructive ones, are silent in their operations; but when Science detects a silent, insidious enemy to human welfare, it is not only our duty to assume an attitude of self-defense and self-protection, but it should be regarded as folly not to do so.’ ❦ On high CO₂ levels connected to poor performance in schools: ‘The effects of breathing impure air thus far considered are pathological, but it has its pedagogical and economical aspects. Every observing teacher knows the immediate relation between the vitiated air in the school-room and the work he wishes the pupils to perform. Much of the disappointment of poor lessons and the tendency to disorder are due directly to this cause. The brain unsupplied with a proper amount of pure blood [oxygen] refuses to act, and the will is powerless to arouse the flagging energies; the general feeling of discomfort, dissatisfaction, and unrest which always accompanies a bad state of the blood. From an economical standpoint it would, of course, be impossible to estimate the financial waste of breathing impure air, but it can not but be enormous. In any discussion of the feasibility of incurring the additional expense of the most perfect ventilation, this loss occasioned by the want of such ventilation must not be ignored.’ ❂ Chapter III: The Air (pp.25-26) ❦ On ventilation, air filtration, and the super-spreading of diverse diseases in classrooms: ‘Wherever an unusual amount of unwholesome matter is being evolved, there especially should the purifying conditions be present; air in such places, to remain pure, must be changed in rapid succession, in order that dilution, diffusion, and oxidation may fulfill their legitimate functions. In a school-room the contaminating process can not but be rapid, and wherever ample provision is not made for rapidly changing the air of the room a dangerous condition of affairs is sure to exist. Bacteria of many forms, and spores of fungi, are also found in the air, and all these organisms are known to thrive in the organic impurities found in the air.’ ❂ Chapter IV: Examination Of The Air (p.33) ❦ On measuring CO₂ levels as a proxy to establishing content of (infectious) re-breathed air: ‘A complete analysis of impure air comprehends the quantitative and qualitative tests for carbonic [sic] dioxide, free ammonia, and other nitrogenous matter, oxidizable matters, nitrous and nitric acids, and hydrogen sulphide; but for ordinary practical purposes the determination of the CO₂ is by far the most important, and is ordinarily the only one which need be made. While the poisonous qualities of the air are not wholly due to the presence of the CO₂ per se, the amount of this gas found to be present is, in air made impure by respiration, generally a good measure for other impurities to which the poisonous quality is principally due. Owing to this fact, a careful test for the amount of CO₂ contained in a given atmosphere is generally the only one which need be made where air is tested merely to determine its respiratory purity.’ ❂ 📖 (Accessed 10 Apr 2024 ~ D. Appleton & Company / Google Books) The Ventilation and Warming of School Buildings ➤ ❂ My thanks to Maarten De Cock for alerting me to this gem of a book. ➲

‘ Reinfection , which is now the dominant type of SARS-CoV-2 infection , is not inconsequential ; it can trigger de novo Long Covid or exacerbate its severity . Each reinfection contributes additional risk of Long Covid: cumulatively , two infections yield a higher risk of Long Covid than one infection , and three infections yield a higher risk than two infections .’

‘The very first canon of nursing... the first essential to the patient... is this: to keep the air he breathes as pure as the external air, without chilling him .’ ❂ Notes on Nursing (1860 edition) By Florence Nightingale First Published 1859. Revised edition reprinted in 1860 by Harrison of Pall Mall Accessed 19 Feb 2024 ❦ Chapter I – Ventilation and Warming ‘The very first canon of nursing, the first and the last thing upon which a nurse’s attention must be fixed, the first essential to the patient, without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM. Yet what is so little attended to? Even where it is thought of at all, the most extraordinary misconceptions reign about it. Even in admitting air into the patient’s room or ward, few people ever think where that air comes from. It may come from a corridor into which other wards are ventilated, from a hall, always unaired, always full of the fumes of gas, dinner, of various kinds of mustiness; from an underground kitchen, sink, wash-house, water-closet, or even, as I myself have had sorrowful experience, from open sewers loaded with filth; and with this the patient’s room or ward is aired, as it is called – poisoned, it should rather be said. Always air from the air without, and that, too, through those windows, through which the air comes freshest. From a closed court, especially if the wind do not blow that way, air may come as stagnant as any from a hall or corridor. I know an intelligent humane house surgeon who makes a practice of keeping the ward windows open. The physicians and surgeons invariably close them while going their rounds; and the house surgeon, very properly, as invariably opens them whenever the doctors have turned their backs. I have known a medical officer keep his ward windows hermetically closed, thus exposing the sick to all the dangers of an infected atmosphere, because he was afraid that, by admitting fresh air, the temperature of the ward would be too much lowered. This is a destructive fallacy. To attempt to keep a ward warm at the expense of making the sick repeatedly breathe their own hot, humid, putrescing atmosphere is a certain way to delay recovery or to destroy life.’ ❂ ‘I have known cases of hospital pyæmia quite as severe in handsome private houses as in any of the worst hospitals, and from the same cause, viz., foul air. Yet nobody learnt the lesson. Nobody learnt anything at all from it.’ ❂ ✪ C-19: On schools ‘Of all places, public or private schools, where a number of children or young persons sleep in the same dormitory * , require this test of freshness to be constantly applied.’ * [ C-19 Note: You might substitute ‘sleep’ and ‘dormitory’ with ‘study’ and ‘classroom’ in this section.] ‘If it be hazardous for two children to sleep together in an unventilated bedroom, it is more than doubly so to have four, and much more than trebly so to have six under the same circumstances. People rarely remember this; yet, if parents were as solicitous about the air of school bedrooms as they are about the food the children are to eat, and the kind of education they are to receive, at school, depend upon it due attention would be bestowed on this vitally important matter, and they would cease to have their children sent home either ill, or because scarlet fever or some other “current contagion” had broken out in the school. There are schools where attention is paid to these things, and where “children’s epidemics” are unknown.’ ❂ ✪ C-19: Offices, shops, factories, and other workplaces ‘How much sickness, death, and misery are produced by the present state of many factories, warehouses, workshops, and workrooms!’ ‘How much sickness, death, and misery are produced by the present state of many factories, warehouses, workshops, and workrooms! The places where poor dressmakers, tailors, letter-press printers, and other similar trades have to work for their living, are generally in a worse sanitary condition than any other portion of our worst towns. Many of these places of work were never constructed for such an object. They are badly adapted garrets, sitting-rooms, or bedrooms, generally of an inferior class of house. No attention is paid to cubic space or ventilation. The poor workers are crowded on the floor to a greater extent than occurs with any other kind of over-crowding. The constant breathing of foul air, saturated with moisture, and the action of such air upon the skin renders the inmates peculiarly susceptible of the impression of cold, which is an index indeed of the danger of pulmonary disease to which they are exposed. The result is, that they make bad worse, by over-heating the air and closing up every cranny through which ventilation could be obtained. In such places, and under such circumstances of constrained posture, want of exercise, hurried and insufficient meals, long exhausting labour and foul air – is it wonderful that a great majority of them die early of chest disease, generally of consumption? Intemperance is a common evil of these workshops. The men can only complete their work under the influence of stimulants, which help to undermine their health and destroy their morals, while hurrying them to premature graves. Employers rarely consider these things. Healthy workrooms are no part of the bond into which they enter with their work-people. They pay their money, which they reckon their part of the bargain. And for this wage the workman or workwoman has to give work, health, and life. Do men and women who employ fashionable tailors and milliners ever think of these things? And yet the master is no gainer. His goods are spoiled by foul air and gas fumes, his own health and that of his family suffers, and his work is not so well done as it would be, were his people in health. And the time will come when it will be found cheaper to supply shops, warehouses, and work-rooms with pure air than with foul air.’ ‘And the time will come when it will be found cheaper to supply shops, warehouses, and work-rooms with pure air than with foul air.’ ❂ ✪ C-19: On ‘air-tests’, and measuring CO₂ as a proxy for estimating prevalence of airborne disease indoors ‘Dr. Angus Smith’s air-test, if it could be made of simple application, would be invaluable to use in every sleeping and sick room. Just as without the use of a thermometer no nurse should ever put a patient into a bath, so, if this air-test were made in some equally simple form, should no nurse, or mother, or superintendent, be without it in any ward, nursery, or sleeping-room. But to be used, the air-test must be made as simple a little instrument as the thermometer, and both should be self-registering. ‘...the air-test must be made as simple a little instrument as the thermometer, and both should be self-registering.’ The senses of nurses and mothers become so dulled to foul air that they are perfectly unconscious of what an atmosphere they have let their children, patients, or charges sleep in. But if the tell-tale air-test were to exhibit in the morning, both to nurses and patient and to the superior officer going round, what the atmosphere has been during the night, I question if any greater security could be afforded against a recurrence of the misdemeanour.’ ❂ ✪ C-19: ... And back to the school-room, testing its air, and combatting airborne pathogens ‘And, oh! the crowded national school! where so many children’s epidemics have their origin; and the crowded, unventilated work-room, which sends so many consumptive men and women to the grave; what a tale its air-test would tell! We should have parents saying, and saying rightly, “I will not send my child to that school. I will not trust my son or my daughter in that tailor’s or milliner’s workshop, the air-test stands at ‘Horrid.’” ‘We should have parents saying, and saying rightly, “I will not send my child to that school... the air-test stands at Horrid .”’ And the dormitories of our great boarding schools! Scarlet fever would be no more ascribed to contagion but to its right cause, the air-test standing at “Foul.” We should hear no longer of “mysterious dispensations,” nor of “plague and pestilence” being “in God’s hands,” when, so far as we know, He has put them into our own. The little air-test would both betray the cause of these “mysterious pestilences,” and call upon us to remedy it.’ ❂ ❦ Chapter II – Health of Houses ‘There are five essential points in securing the health of houses:– Pure air. Pure water. Efficient drainage. Cleanliness. Light. Without these, no house can be healthy. And it will be unhealthy just in proportion as they are deficient. To have pure air, your house must be so constructed as that the outer atmosphere shall find its way with ease to every corner of it. ‘To have pure air, your house must be so constructed as that the outer atmosphere shall find its way with ease to every corner of it.’ House architects hardly ever consider this. The object in building a house is to obtain the largest interest for the money, not to save doctor’s bills to the tenants. But, if tenants should ever become so wise as to refuse to occupy unhealthily constructed houses, and if Insurance Companies should ever come to understand their interest so thoroughly as to pay a Sanitary Surveyor to look after the houses where their clients live, speculative architects would speedily be brought to their senses. As it is, they build what pays best. And there are always people foolish enough to take the houses they build. And if in the course of time the families die off, as is so often the case, nobody ever thinks of blaming any but Providence for the result. Ill-informed medical men aid in sustaining the delusion, by laying the blame on “current contagions”. Badly constructed houses do for the healthy what badly constructed hospitals do for the sick.’ ‘Badly constructed houses do for the healthy what badly constructed hospitals do for the sick.’ ❂ ❦ Conclusion ‘The whole of the preceding remarks apply even more to children and to puerperal women than to patients in general. They also apply to the nursing of surgical, quite as much as to that of medical cases. Indeed, if it be possible, cases of external injury require such care even more than sick. In surgical wards, one duty of every nurse certainly is prevention. Fever, or hospital gangrene, or pyæmia, or purulent discharge of some kind may else supervene. If she allows her ward to become filled with the peculiar close fœtid smell, so apt to be produced among surgical cases, especially where there is great suppuration and discharge, she may see a vigorous patient in the prime of life gradually sink and die where, according to all human probability, he ought to have recovered. The surgical nurse must be ever on the watch, ever on her guard, against want of cleanliness, foul air, want of light, and of warmth.’ ‘In surgical wards, one duty of every nurse certainly is prevention.’ ❂ 📖 (Accessed 19 Feb 2024 ~ Original text copied from FiftyWordsForSnow.com) Notes on Nursing (1860) ➤ 📖 (Accessed 19 Feb 2024 ~ Original scanned pages from Google Books) Notes on Nursing (1860) ➤ ❂

❦ I accept that school boards ultimately do not care about the safety of their students and staff. But a HEPA air purifier costs less than a few days of sub coverage. Add a $1 mask/day x 180 school days, and that’s another day of sub coverage. You don’t incur the disruption to education delivery that happens when a sub comes in. You’re not potentially permanently disabling education workers. The “school boards are cash-strapped” excuse makes no sense when the solution to constant sickness is: “We’ve got more subs!” © 2023 Amanda Hu . ➲

❦ Children have largely been unaffected by severe COVID-19 compared to adults, but data suggest that they may have experienced new conditions after developing the disease. We compared 1656 exposed and 1656 unexposed children from 1 February 2020 to 30 November 2021. We found significantly higher risks for some new conditions in exposed children, including mental health issues and neurological problems . The overall excess risk for new-onset conditions after COVID-19 was 78% higher in the exposed than unexposed children. ❂ 📖 (9 Sep 2023 ~ Acta Paediatrica) Comparative study showed that children faced a 78% higher risk of new-onset conditions after they had COVID-19 ➤ © 2023 Di Chiara et al / Acta Paediatrica.

❦ Since the pandemic began, I have constantly made the argument that a healthy workforce is a necessity for a healthy economy. This, to me, is the definition of obvious. The same argument applies to education. I’m writing this because I’ve received a large number of messages and e-mails this week from parents who are being placed under extreme pressure by schools in an attempt to stop their children trying to avoid infection. Let me be very, very clear: education is extraordinarily important. Health is extraordinarily important. A child’s education will suffer if that child is unwell. Again, the definition of obvious. Parents should not be put in a position in which they are being forced to choose between their child’s health and their child’s education. It is a false dichotomy that mirrors the pernicious culture of presenteeism that is sadly still present in many workplaces. It’s also driven by the nature of box-ticking bureaucracies that always seek to maintain the status quo. This is both an ethical and pragmatic argument. Ethical, because placing pressure on parents to have to choose between access to education and near-certain infection of their children is morally wrong. And, believe me, I make moral statements carefully. Pragmatic, because if schools simply introduced air-filtration as standard, and encouraged parents to keep children with acute Covid off school, there would be far, far less transmission in schools – thus improving the quality of education for all. Again, the definition of obvious. Much like the economy, we need to employ medium- and long-term thinking now, rather than short-term thinking that clings to the status quo purely for its own sake. And remember, reduction of transmission in schools reduces transmission in the wider community. As such, this means that less adults are sick at any given time, which is also good for the economy. This is so clear that it baffles me that most policy-makers seem to fail to understand it. © 2023 Conor Browne . ➲

❦ ‘The magnitude of the outbreak illustrates how younger children infected from diverse pediatric facilities can be a major source of widespread household transmission with the potential to facilitate community transmission in the era of the Omicron variant. With highly transmissible variants such as the Omicron (B.1.1.529) variant of concern (VOC) and its subvariants becoming dominant globally, the role of children in transmission dynamics needs to be elucidated to take tailored public health and social measures for the control of outbreaks and pandemics. On epidemiological investigation, frequent and intimate interactions among children, along with inadequate indoor ventilation, were commonly observed in pediatric facilities. Given the practical challenges of behavior modification among pediatric populations, including consistent and correct mask use and physical distancing, the environmental control interventions, such as improved ventilation systems, upper-room ultraviolet germicidal irradiation, or portable high-efficiency particulate air-filtration appliances, may offer sustained benefits in stemming the virus transmission in pediatric facilities.’ ❂ 📖 (20 Apr 2023 ~ Yonsei Medical Journal) Widespread Household Transmission of SARS-CoV-2 B.1.1.529 (Omicron) Variant from Children, South Korea, 2022 ➤ © 2023 Park et al / Yonsei Medical Journal.

❦ ‘A recent US Centers for Disease Control and Prevention (CDC) analysis of 1.4 million children aged under 12 years and 1.7 million adolescents aged 12-17 years found increased rates of asthma, myocarditis and cardiomyopathy, cardiac dysrhythmias, diabetes, renal failure, venous thromboembolism, and coagulation disorders in children with laboratory-confirmed COVID-19 compared with children without COVID-19. These increased risks (excluding asthma) were also experienced by adolescents with COVID-19, who were additionally at increased risk of pulmonary embolism. Although uncommon or rare, such outcomes suggest children are not spared the cardiovascular and metabolic sequelae of COVID-19. Reinfection is common and SARS-CoV-2 spreads readily in schools in the absence of mitigation measures, such as the use of masks, portable HEPA air cleaners, and improved ventilation. Notably, better ventilation has wider benefits, including improved academic performance. (A poorly-ventilated classroom can be equivalent to a student skipping breakfast.) The COVID-19 pandemic is not over. On-going commitment to a public health strategy informed by the precautionary principle is required. This will deliver wide-ranging social, economic and health benefits.’ ❂ 📖 (20 Feb 2023 ~ The Medical Journal of Australia) Balancing the medical and social needs of children during the COVID‐19 pandemic ➤ 📖 Related: (April 2021 ~ The Lancet COVID-19 Commission) The Lancet COVID‐19 Commission Task Force on Safe Work, Safe School, and Safe Travel. Designing infectious disease resilience into school buildings through improvements to ventilation and air cleaning ➤ © 2023 Zoë Hyde / The Medical Journal of Australia.

❦ ‘Death is not the main risk facing most children. Disability is. Research shows the risks of harm and disability from COVID infection are serious, and risks accumulate with additional reinfections. It isn’t surprising that COVID can cause long term downstream problems — many other viruses do as well. What is new is we have essentially the fastest spreading airborne virus in recorded history, which gets into blood vessels and can damage almost every part of the body. Despite this, it often presents acutely with only respiratory symptoms, drawing false equivocation to the common cold. And it mutates such that everyone can get it over and over. We fundamentally do not know the extent of the long-term damage continual reinfection with COVID will cause to children, and the data we have so far are upsetting. What are we willing to risk? Are we OK with more children contracting diabetes ? Are we OK with many more children developing highly disabling orthostatic intolerance ? How about chronic fatigue, cognitive impairment, sleep disorders and heart problems? Are we OK with children being hospitalized for infectious diseases at far higher rates, as they have recently been? Are we fine with COVID being the No. 1 cause of infectious disease-driven death in children? Also, what if there is a number of reinfections at which average outcomes really start to worsen? In spite of all the evidence for caution, we are now tossing children into a world with nearly zero protections. Without new silver bullet scientific discoveries, young children will be pretty much guaranteed to contract new COVID variants over a dozen times by the time they reach adulthood. Current vaccines make a dent in long COVID but do not prevent it as well as they protect against severe acute disease. We are just hoping kids will be OK. I don’t see how they will be. The data suggest they won’t be. The solutions for protecting kids can be gleaned from behaviours of wealthy elites, and they involve layering protections to create clean indoor air. The recent World Economic Forum in Davos used the following safety systems: mandatory daily PCR testing with ID-badge access linked to results, new “state-of-the-art ventilation systems” , HEPA air purifiers everywhere, various levels of masking and, it appeared, virus-killing UV lighting systems. Our children deserve these protections, in their schools and elsewhere. These measures, along with boosters, are in fact the only currently existing ways of reducing the public health need for universal indoor masking. By treating children as invulnerable we are actually treating them as disposable. But they are everything – to our lives and to our future. Their long-term health is at risk... and we need to protect them.’ ❂ 📖 (14 Feb 2023 ~ Calgary Herald) Treating kids as invulnerable is treating them as disposable ➤ 📖 Related: (11 Jun 2019 ~ Our World In Data) Mortality in the past – around half died as children ➤ 📖 Related: Guidance on Health Measures for the World Economic Forum 2023 Annual Meeting at Davos, Switzerland ➤ © 2023 Blake Murdoch / Calgary Herald.

❦ ‘Children have largely avoided severe COVID-19 symptoms because they have a strong initial ‘innate’ immune reaction that quickly defeats the virus. But unlike those of adults, children’s immune systems don’t remember the virus and don’t adapt, so when they’re next exposed to SARS-CoV-2, their body still treats it as a new threat. “Because children haven’t been exposed to many viruses, their immune system is still ‘naive’. And because they don't develop memory T cells, they are at risk of getting sick when they become reinfected. With each new infectious episode as they get older, there is a risk of their T cells becoming ‘exhausted’ and ineffective, like the T cells in older people. The price that children pay for being so good at getting rid of the virus in the first place is that they don’t have the opportunity to develop ‘adaptive’ memory to protect them the second time they are exposed to the virus,” says Professor Tri Phan.’ ❂ 📖 (26 Jan 2023 ~ Medical Life Sciences) Children's immune systems do not develop 'adaptive' memory to protect against second-time SARS-CoV-2 infection ➤ 📖 (January 2023 ~ Clinical Immunology) Tracking the clonal dynamics of SARS-CoV-2-specific T cells in children and adults with mild/asymptomatic COVID-19 ➤ © 2023 Emily Henderson / Medical Life Sciences.

❦ ‘Long COVID impacts children of all ages . Children with Long COVID experience fatigue, post-exertional malaise (PEM), cognitive dysfunction, memory loss, headaches, orthostatic intolerance, sleep difficulty and shortness of breath. ❦ Post-exertional malaise (PEM) = The worsening of symptoms following even minor physical or mental exertion, with symptoms typically worsening 12 to 48 hours after activity and lasting for days or even weeks. ❦ Cognitive dysfunction = deficits in attention, verbal and non-verbal learning, short-term and working memory, visual and auditory processing, problem solving, processing speed, and motor functioning. ❦ Orthostatic intolerance = The inability to remain upright without symptoms. Liver injury has been recorded in children who were not hospitalized during acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, and although rare, children who had COVID-19 have increased risks of acute pulmonary embolism, myocarditis and cardiomyopathy, venous thromboembolic events, acute and unspecified renal failure, and type 1 diabetes. Infants born to women who had COVID-19 during pregnancy were more likely to receive a neurodevelopmental diagnosis in the first year after delivery. A paediatric Long COVID centre’s experience treating patients suggests that adolescents with a moderate to severe form of Long COVID have features consistent with myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS) . ❦ Myalgic encephalomyelitis / Chronic fatigue syndrome = (ME/CFS) is a condition that causes extreme tiredness and a range of other symptoms. Other symptoms of ME/CFS may include: ⊙ Tender lymph nodes in the neck or armpits. ⊙ A sore throat that happens often. ⊙ Digestive issues, like irritable bowel syndrome. ⊙ Chills and night sweats. ⊙ Allergies and sensitivities to foods, odors, chemicals, light, or noise. ⊙ Muscle weakness. ⊙ Shortness of breath. ⊙ Irregular heartbeat. Children experiencing Long COVID have hypometabolism in the brain similar to the patterns found in adults with Long COVID. ❦ Hypometabolism in the brain = Characterized by decreased brain glucose consumption, is a common feature of many neurodegenerative diseases . The initial hypometabolic brain state created by characteristic risk factors may predispose the brain to acquired epilepsy and sporadic Alzheimer's and Parkinson's diseases . Long-term pulmonary [lung] dysfunction is found in children with Long COVID, and in those who have recovered from COVID-19. Children with Long COVID were more likely to have had attention deficit hyperactivity disorder, chronic urticaria and allergic rhinitis before being infected. Fatigue, headache, dizziness, dyspnoea, chest pain, dysosmia, dysgeusia, reduced appetite, concentration difficulties, memory issues, mental exhaustion, physical exhaustion and sleep issues were between 2 and 36 times more likely in individuals with Long COVID aged 15-19 .’ ❦ Dyspnoea = shortness of breath, or breathlessness. ❦ Dysosmia = a change in the ability to smell. ❦ Dysgeusia = a change in perception of taste. ❂ 📖 (13 Jan 2023 ~ Nature Reviews: Microbiology) Long COVID in children ➤ 📖 (13 Jan 2023 ~ Nature Reviews: Microbiology) Long COVID: major findings, mechanisms and recommendations ➤ © 2023 Nature.

❦ ‘In 2021, SARS-CoV-2-related severe neurologic involvement in US hospitalized children and adolescents showed a potential increase in diagnoses of acute central nervous system infections / demyelination. In this case series of 2168 US patients younger than 21 years hospitalized for acute COVID-19 (34%) or multisystem inflammatory syndrome in children (66%), 476 (22%) had neurologic involvement. Of these, 42 (9%) had life-threatening conditions, with 23 (55%) having acute central nervous system (CNS) infections / demyelination; 18 of 42 (43%) died or had new neurologic deficits; and most vaccine-eligible patients were unvaccinated.’ ❂ 📖 (1 Jan 2023 ~ JAMA Network / Neurology) Changes in Distribution of Severe Neurologic Involvement in US Pediatric Inpatients With COVID-19 or Multisystem Inflammatory Syndrome in Children in 2021 vs 2020 ➤ 📖 Related: (5 Jan 2023 ~ Neurology Today) Nearly One-Fifth of Hospitalized Children and Adolescents with SARS-CoV-2 or MIS-C Have Persistent Neurologic Complications ➤ © 2023 LaRovere et al / JAMA: Neurology.

❦ ‘Our findings shed new light on the cardiac impact of COVID-19 in paediatric age. 60% of children who recovered from asymptomatic or mildly symptomatic COVID-19 still exhibit mild subclinical systolic cardiac impairment after an average follow-up.’ ❂ 📖 (26 Dec 2022 ~ Journal of Clinical Medicine) Mid- and Long-Term Atrio-Ventricular Functional Changes in Children after Recovery from COVID-19 ➤ © 2022 Journal of Clinical Medicine .

❦ “During my young and ‘indestructible’ days, I did a lot of risky things. I now have a dodgy ankle, and various other aches and pains to remind me... Young people these days will also accumulate their scars of youth... but in my opinion, the COVID scars were unnecessary. We could have made it so much safer to travel and have fun by controlling disease properly. We gave up on them, our youth. We left them last for vaccines, and last for any consideration of their needs. They can’t even date properly without excess risk of long-term health problems because we can’t be bothered to do the work. Dating and finding a partner is a need , by the way. Sure, there are ways around this… but realistically, zero COVID would have been for them. The young. People think it’s to protect the old... but that’s only a small part of the story! Zero COVID would have given our kids safer schools. Parties would be safer. Sport would be safer, and they could excel without fear of COVID ruining their goals. We should have done it for the kids. See what I mean. We have misguided and abandoned them.”

❦ ‘The prevalence of Long COVID in children and adolescents was 25.24% . The five most prevalent clinical manifestations were mood symptoms (16.50%), fatigue (9.66%), sleep disorders (8.42%), headache (7.84%), and respiratory symptoms (7.62%). Interestingly, many of the symptoms identified in these meta-analyses associated to Long COVID, such as mood, fatigue, sleep disorders, orthostatic intolerance, decreased concentration, confusion, memory loss, balance problems, exercise intolerance, hyperhidrosis, blurred vision, body temperature dysregulation, dysfunction on heart, rate variability and palpitations, constipation or diarrhea, and dysphagia, are commonly present in dysautonomia .’ ❂ 📖 (23 Jun 2022 ~ Nature Scientific Reports) Long COVID in children and adolescents: a systematic review and meta-analyses ➤ © 2022 Lopez-Leon et al / Nature.

❦ ‘Babies whose mothers were infected with the coronavirus during pregnancy may face a higher risk of brain development disorders such as autism and bipolar disorder, a new study that examined more than 7,500 births suggests. Other viruses, such as influenza and measles, are thought to make babies more vulnerable to conditions such as autism, schizophrenia and depression if they are exposed in utero. After the researchers accounted for other factors that could affect a child’s risk for a neurodevelopmental issue — such as pre-term births, the mother’s age and the baby’s gender — they calculated that babies with prenatal exposure to SARS-CoV-2 were 86% more likely to be diagnosed in their first year compared with babies who weren’t exposed before they were born. “Unfortunately, it is very possible that asymptomatic or mild infections might also be linked to neurodevelopmental disorders in the child.” The medical advice for pregnant women remains unchanged. “This should be another wake-up call for pregnant women to get vaccinated, and boosted, and stay masked and take as many precautions as they can.” ❂ 📖 (10 Jun 2022 ~ LA Times) Coronavirus infection during pregnancy linked to brain development problems in babies ➤ 📖 (9 June 2022 ~ JAMA Network Open) Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy ➤ © 2022 Sumeet Kulkarni / LA Times

❦ ‘In this analysis of 222 offspring of mothers infected with SARS-CoV-2, compared with the offspring of 7550 mothers in the control group (not infected) delivered during the same period, we observed neurodevelopmental diagnoses to be significantly more common among exposed offspring, particularly those exposed to third-trimester maternal infection . The majority of these diagnoses reflected developmental disorders of motor function or speech and language .’ ❂ 📖 (9 Jun 2022 ~ JAMA: Pediatrics) Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy ➤ © 2022 Edlow et al / JAMA: Pediatrics.

❦ ‘The authors performed a survey in children suffering from persistent symptoms since initial infection. A total of 510 children infected between January 2020 and January 2021 were included. Symptoms such as fatigue, headache, muscle and joint pain, rashes and heart palpitations and issues such as lack of concentration and short-term memory problems were particularly frequent and confirm previous observations, suggesting that they may characterize this condition.’ ❂ 📖 (1 Apr 2022 ~ Future Microbiology) Clinical characteristics, activity levels and mental health problems in children with long coronavirus disease: a survey of 510 children ➤ © 2022 Buonsenso et al / Future Microbiology.

❦ ‘Fatigue in this [adolescent] population often leads to difficulty with physical and cognitive activity , which can limit participation in school, extracurricular activities, and sports. Excessive sleep , problems initiating or maintaining sleep, or non-refreshing sleep often accompany fatigue in pediatric long COVID. Fatigue may persist even with an improvement in sleep patterns. Post-exertional malaise (PEM) is also common in Long COVID. PEM refers to an exacerbation not just of fatigue, but of many symptoms, including light-headedness, cognitive fogginess, sensory sensitivity, headaches and pain, occurring after relative increases in physical activity or cognitive demands. Cognitive difficulties or "brain fog" are also commonly reported by children with Long COVID. Cognitive difficulties tend to include problems with concentration, short-term memory, and school performance. Fatigue or low energy is one of the most common symptoms reported in children with Long COVID, with recent studies suggesting that up to 87% of affected children report fatigue . Headaches are also commonly reported both in the acute and post-acute phase of COVID in children. Many patients also report orthostatic symptoms , including lightheadedness or dizziness, syncope, blurred vision, exercise intolerance, dyspnea, chest discomfort, palpitations, tremulousness, anxiety, diaphoresis, and nausea. ❦ Syncope ('sink-euh-pee') = fainting or losing consciousness. ❦ Dyspnea = shortness of breath or breathlessness. ❦ Diaphoresis = excessive sweating due to a secondary condition. Cardiopulmonary symptoms : Many adolescents have reported a variety of cardiopulmonary symptoms including dyspnea, chest pain or tightness, and cough. Mental health and behavioral symptoms also are prominent in this population, with anxiety and depression being the most prevalent. Changes in taste and smell including anosmia, ageusia, parosmia, and dysgeusia are reported with acute SARS-CoV-2 infection in children and adults.’ ❦ Anosmia = partial or full loss of smell. ❦ Ageusia = loss of taste. ❦ Parosmia = a distorted sense of smell (eg. things that used to smell pleasant now smell foul to people with parosmia). ❦ Dysgeusia = a taste disorder (eg. people with dysgeusia feel that all foods taste sour, sweet, bitter or metallic). ❂ 📖 (9 Mar 2022 ~ Adolescent Medicine) Long-Term COVID 19 Sequelae in Adolescents: The Overlap with Orthostatic Intolerance and ME/CFS ➤ © 2023 Adolescent Medicine.

❦ ‘ Fatigue in this population often leads to difficulty with physical and cognitive activity, which can limit participation in school, extracurricular activities, and sports. Excessive sleep , problems initiating or maintaining sleep, or non-refreshing sleep often accompany fatigue in pediatric long COVID. Fatigue may persist even with an improvement in sleep patterns. Post-exertional malaise (PEM) is also common in Long COVID. PEM refers to an exacerbation not just of fatigue, but of many symptoms, including light-headedness, cognitive fogginess, sensory sensitivity, headaches and pain, occurring after relative increases in physical activity or cognitive demands. Cognitive difficulties or "brain fog" are also commonly reported by children with Long COVID. Cognitive difficulties tend to include problems with concentration , short-term memory , and school performance . Headaches are also commonly reported both in the acute and post-acute phase of COVID in children. Many patients also report orthostatic symptoms , including lightheadedness or dizziness, syncope, blurred vision, exercise intolerance, dyspnea, chest discomfort, palpitations, tremulousness, anxiety, diaphoresis, and nausea. ❦ Syncope ('sink-euh-pee') = Fainting or losing consciousness. ❦ Dyspnea = Shortness of breath or breathlessness. ❦ Diaphoresis = Excessive sweating due to a secondary condition. Cardiopulmonary symptoms : Many adolescents have reported a variety of cardiopulmonary symptoms including dyspnea, chest pain or tightness, and cough. Mental health and behavioral symptoms also are prominent in this population, with anxiety and depression being the most prevalent. Changes in taste and smell including anosmia, ageusia, parosmia, and dysgeusia are reported with acute SARS-CoV-2 infection in children and adults.’ ❦ Anosmia = Partial or full loss of smell. ❦ Ageusia = Loss of taste. ❦ Parosmia = A distorted sense of smell (eg. things that used to smell pleasant now smell foul to people with parosmia). ❦ Dysgeusia = A taste disorder (eg. people with dysgeusia feel that all foods taste sour, sweet, bitter or metallic). ❂ 📖 (9 Mar 2022 ~ Adolescent Medicine) Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS ➤ © 2022 Morrow et al / Adolescent Medicine.

❦ ‘A quarter of children experienced persistent symptoms months after COVID-19 infection, with almost one in 10 experiencing multisystem involvement. Older age and allergic diseases were associated with higher risk of persistent symptoms at follow-up.’  ❂ 📖 (3 Feb 2022 ~ European Respiratory Journal) Risk factors for post-COVID-19 condition in previously hospitalised children using the ISARIC Global follow-up protocol: a prospective cohort study ➤ © 2022 Osmanov et al / European Respiratory Journal.

❦ ‘SARS-CoV-2 infection may affect left ventricular deformation in 26% of children despite an asymptomatic or only mildly symptomatic acute illness. A follow-up is needed to verify the reversibility of these alterations and their impact on long-term outcomes.’  ❂ 📖 (5 July 2021 ~ European Heart Journal: Cardiovascular Imaging) Left ventricular longitudinal strain alterations in asymptomatic or mildly symptomatic paediatric patients with SARS-CoV-2 infection ➤ © 2021 Sirico et al / European Heart Journal: Cardiovascular Imaging.

❦ BUILDINGS PLAY A CRITICAL ROLE IN THE TRANSMISSION OF AIRBORNE INFECTIOUS DISEASES. ‘Buildings play a critical role in minimizing, or conversely exacerbating, the spread of airborne infectious diseases. COVID-19 outbreaks occur indoors, and within-room long-range transmission beyond two meters (six feet) has been well documented in conditions with no masking and low ventilation rates. However, the relationship between building systems and airborne infectious disease transmission predates SARS-CoV-2, the virus that causes COVID-19. Building-related interventions have been shown to reduce the spread of many other airborne infectious diseases, including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), tuberculosis, measles, and influenza. Following the 2009 H1N1 influenza A pandemic, an epidemiological investigation at a boarding school in Guangzhou, China found that opening windows for outdoor air ventilation was the only control measure that had significantly protected against infection. Other research confirmed that enhanced outdoor air ventilation can reduce influenza and tuberculosis transmission in school buildings. Similarly, upper-room ultraviolet (UV) germicidal irradiation installed in Philadelphia-area schools substantially reduced measles spread during an epidemic. As of early 2021, no in situ research has evaluated the independent impact of ventilation and air cleaning for reducing the risk of COVID-19 transmission in schools. However, there are a number of studies in which enhanced ventilation was used as part of layered risk reduction strategy, resulting in the successful reduction of COVID-19 infections. For example, COVID-19 cases and mitigation strategies were tracked in schools in two cities in Missouri in December 2020. Schools that used a combination of mitigation strategies including improved outdoor air ventilation were found to have lower rates of transmission compared to the rest of the community. COVID-19 transmission among children in Baden-Württemberg, Germany was also rare in schools and childcare settings that employed mitigation strategies which included improved ventilation. Conversely, inadequate outdoor air ventilation has been explicitly implicated in several large COVID-19 outbreaks across various indoor environments. Case studies have included a choir rehearsal with poor ventilation and no masks; a meat processing facility with low air exchange rates and high rates of unfiltered recirculated air; a spin class without masks and inadequate air circulation; a bus with an air conditioning system on recirculating mode, and a restaurant with poor ventilation and an air conditioner that recirculated air through the dining room. These counterexamples demonstrate that building-level strategies, including ventilation and air cleaning, are key components of risk reduction strategies for airborne infectious diseases, including COVID-19.’ ‘Schools are chronically under-ventilated.’ ❂ 📖 (April 2021 ~ The Lancet COVID-19 Commission) The Lancet COVID‐19 Commission Task Force on Safe Work, Safe School, and Safe Travel. Designing infectious disease resilience into school buildings through improvements to ventilation and air cleaning ➤ © 2021 The Lancet COVID-19 Commission.

❦ ‘A total of 286 children from 55 centers in 17 European countries were included. The median age was 8.4 years (interquartile range, 3.8-12.4 years) and 67% were boys. The most common cardiovascular complications were shock, cardiac arrhythmias, pericardial effusion, and coronary artery dilatation. Cardiac involvement is common in children with multisystem inflammatory syndrome associated with the Covid-19 pandemic.’  ❂ 📖 (9 Nov 2020 ~ Circulation) Acute Cardiovascular Manifestations in 286 Children With Multisystem Inflammatory Syndrome Associated With COVID-19 Infection in Europe ➤ © 2020 Valverde et al / Circulation.