Monday, May 16, 2022

Covid-19 safety doesn’t have to be all or nothing. Here’s how to think about it going forward.

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Shreya Christinahttps://cafe-madrid.com
Shreya has been with cafe-madrid.com for 3 years, writing copy for client websites, blog posts, EDMs and other mediums to engage readers and encourage action. By collaborating with clients, our SEO manager and the wider cafe-madrid.com team, Shreya seeks to understand an audience before creating memorable, persuasive copy.

The staggering winter omicron surge has receded in the US, but this pandemic isn’t over. Nearly 700 Americans, on average, are still dying of Covid-19 every single day, and cases recently spiked in Europe due to the BA.2 variant. This means a lot of people are, once again, unsure of the best way to proceed in their personal lives. Is it a bad idea to do indoor dining where you live right now? Visit with elderly relatives? Get on a plane to take the trip you booked last summer? If you have to show up at work every day, should you still be wearing a high-quality mask around your coworkers?

It can be frustratingly difficult to get straight answers. Much of the pandemic behavioral advice that does exist is still centered on assessing one’s personal risk, and the idea that once you’re vaccinated and boosted, you have nothing to worry about. “The communication around this has been abysmal,” Katelyn Jetelina, an assistant professor of epidemiology at the University of Texas Health Science Center at Houston and the author of the Your Local Epidemiologist newsletter, tells cafemadrid. “There’s no top-down guidance at all.”

There’s an even more significant dearth of information if you’re not young and healthy, or if you’re concerned about your personal impact on high-risk loved ones, exhausted health care workers, or strained hospitals. It’s not always clear how we might meaningfully protect the vulnerable folks in our communities, though immunocompromised people, people who are 65 and older, and people with disabilities remain at higher risk of complications and death even if they are vaccinated and boosted.

While we absolutely need federal and state governments to do more to keep us safe (please, we’re literally begging you to upgrade schools’ ventilation systems, buy extra doses of antiviral pills and fund coronavirus aid, make it easier for people to access Paxlovid and Evusheld, and help vaccinate the world), we also can’t wait around for those structural changes to come through. We want and need to make smart personal choices, and also acknowledge that personal choices play a huge role in public health.

Jetelina says the best time to adjust your behavior is before hospitals start to feel a strain. “It’s all about level of transmission in the community,” Jetelina says. “If the virus is circulating at really high rates, then the odds of you bringing the virus to your work or community is much higher than if the transmission in the community is low. Behaviors should reflect those transmission levels.”

So what, exactly, counts as a “high” rate of spread? Here’s how, specifically, to think about pandemic safety and precautions based on Covid-19 data in the coming months.

How to think about the latest CDC guidance

At the end of February, the CDC announced new guidelines for mask mandates that incorporated three data points: new Covid-19 hospital admissions over the previous week, percentage of hospital beds occupied by Covid-19 patients, and new Covid-19 cases per 100,000 people over the previous week. Prior to these new guidelines, the CDC recommended masking indoors once weekly cases were at or above 50 per 100,000 people. Now, masking isn’t recommended until weekly cases reach 200 or more per 100,000. This change meant much of the country was immediately recategorized as a “low” transmission zone, where masks and social distancing were no longer deemed necessary.

While some people were no doubt thrilled to be given “official” permission, at long last, to unmask indoors in public, the experts who spoke to cafemadrid for this story provided additional context for the new CDC metrics, and said there is still reason for caution. First, they explained, hospitalizations, which now make up two-thirds of the data points, are really about preventing system collapse versus mitigating personal Covid-19 risk or the threat that we as individuals pose to others.

The specifics of the CDC’s guidance change have received some strong pushback. “I very much disagree with the CDC threshold for transmission,” Jetelina says. “I think that there’s a really big distinction that people are missing: The CDC guidance uses 200 cases per 100,000 as a metric that people can take their masks off. But that’s people that can take their masks off because hospitals are not surging. That’s very different than people taking their masks off because the likelihood of infection is reduced. And that nuance — that small distinction — is being lost among the public. I very much think that 200 cases per 100,000 is too high to protect at an individual level.”

As emergency medicine physician Jeremy Faust puts it, the CDC “didn’t really show us their work on how [the new guidelines] protect the immunocompromised.”

“[Cases] are a better measure for returning to protections like mask mandates because we can see cases increasing earlier than we see the downstream effects on hospitals,” says Tara C. Smith, a professor of epidemiology at Kent State University College of Public Health.

To be clear, weekly cases per 100,000 people isn’t a perfect metric. “The data on community transmission is based on lab-reported cases,” says Syra Madad, the senior director of the system-wide special pathogens program at NYC Health + Hospitals. “With widely accessible and highly used rapid at-home tests now, the numbers don’t reflect the whole picture.” (One thing to keep in mind is that local case counts could be a lot higher than what is reflected in health department data.)

“From my perspective, different metrics are useful for different purposes,” says David Dowdy, an infectious disease epidemiologist at Johns Hopkins School of Public Health. “If the goal is to say, ‘What is the burden of Covid right now, how big of a problem is it, how should it be prompting national action?’ then hospitalizations are the right metric. We care about people getting really sick; we don’t care about people getting the equivalent of a sore throat. If the question is about your risk of getting infected at any given time, then local case counts and counts per 100,000 or per population are probably more informative.”

The number of Covid-19 cases in your community can help you assess personal risk and the danger you may pose to others

When community spread is high, says biostatistician Lucy D’Agostino McGowan, “your probability of encountering it is much higher, which then in turn makes your overall probability of a bad outcome higher. When people compare this to the flu, we’ve never had flu seasons where so many people are all sick at the same time.” She says this is significant from both a systems perspective — the hospital can only handle so many patients at a given time — and an individual perspective: If you’re highly likely to encounter Covid-19 when you’re out and about, then the risk of transmitting it to someone else is higher, as is the risk of you getting seriously ill.

Jetelina says that individuals can look at total new cases per 100,000 residents in the past seven days to determine the level of community transmission and to decide what activities they’ll engage in.

One easy way to get these numbers is to use the CDC’s Covid-19 integrated county view. (Note: Many trackers, like the New York Times’s county Covid tracker, show a daily average of cases per 100,000; the advice in this article is based on the weekly number.) Select your state and county from the dropdown menu and the page will update. Under the big bold “COVID-19 Community Level” — which, remember, is calculated using a combination of different metrics — you’ll be able to see the weekly case rate per 100,000.

Once you have your county data, here’s how Jetelina suggests thinking about your behavior and precautions if you’re vaccinated and boosted.

100 or more weekly cases per 100,000 people: high transmission

  • Wear a high-quality mask indoors in public
  • Avoid crowded indoor spaces where people are unmasked and/or where proof of vaccination isn’t required
  • Avoid flying on planes, if possible (Jetelina says the airport, versus the plane itself, is the main source of concern: “You will be walking through clouds of SARS-CoV-2 during a high transmission time,” she says.)
  • Avoid indoor dining
  • Consider crowded private gatherings (like house parties) a high-risk event
  • Be hypervigilant around higher-risk people
  • If you’re symptomatic, it’s probably safe to trust positive results on an antigen test, but if you get a negative antigen test you should test again in 24 hours

50–99.99 cases per 100,000: substantial transmission

  • Wear a high-quality mask indoors in public
  • Avoid crowded indoor spaces where fewer than 75 percent of people are masked and/or where proof of vaccination isn’t required
  • Flying on a plane and doing indoor dining is okay, though ultimately dependent on your personal risk tolerance
  • Consider crowded private gatherings, like house parties, a high-risk event
  • Be vigilant around higher-risk people
  • If you’re symptomatic, trust positive results on an antigen test, but test again in 24 hours if you get a negative antigen test

10–49.99 cases per 100,000: moderate transmission

  • You can be unmasked in public if you’re comfortable with it and aren’t experiencing symptoms or don’t have a known exposure
  • Unvaccinated companions (like, say, children under 5 who are not yet eligible for shots) should wear a high-quality mask in public indoor settings if possible
  • Flying and indoor dining is okay, though ultimately dependent on your personal risk tolerance
  • Be vigilant around higher-risk people
  • If you’re symptomatic, test again in 24 hours if you get a positive test or a negative test

Less than 10 cases per 100,000: low transmission

  • Unvaccinated companions (like, say, your children) should wear a high-quality mask in public indoor settings if possible, but you can be unmasked if you’re comfortable with it and aren’t experiencing symptoms or don’t have a known exposure
  • No restrictions on activities
  • If you’re symptomatic, trust negative results on an antigen test. If you get a positive antigen test, test again in 24 hours

If you live with a young child who can’t be vaccinated, Jetelina says it might make sense to behave as though your county transmission is one level worse than it actually is — e.g., when you’re in the moderate zone, take precautions as though it’s substantial, and when you’re in the high transmission zone, be extremely vigilant.

If all of the above feels overwhelming, one metric Faust suggests — 50 cases per 100,000 — is worth committing to memory. Faust recently did statistical modeling to determine when one-way KN95 or N95 masking would be enough to protect the severely immunocompromised — that is, when people who have zero protection from the vaccines would be fairly safe if they were the only people masked in a public setting. The number he landed on is 50 per 100,000, meaning you may want to mask in public and start making small changes to your behavior (more on that below) to protect others once your community reaches that threshold.

Faust designed his model with the most vulnerable people in mind, meaning the folks with some protection (that is, the vaccines gave them some antibody response, even if it wasn’t as strong as it would be in other people) or who are higher-risk for other reasons will also benefit from others’ precautions. Faust’s article, “When will one-way masking be safe enough for everyone?,” is really worth a read, especially if you’re curious about his methodology and the limitations of this model, but the tl;dr is this: Once your community reaches a weekly average of 50 cases or more per 100,000 people, it’s a good idea to start masking again in public if you want to protect yourself and others.

To protect vulnerable people, take additional precautions in the days following your higher-risk activities

While it’s too soon to declare victory over Covid-19, we know a lot more about mitigation than we did in March 2020, when staying home was the main tool we had. As we enter the third year of this pandemic, high-quality masks, outdoor activities, good indoor ventilation, at-home testing, and limiting contact when you’re symptomatic or have tested positive are crucial aspects of the “Swiss cheese model” of pandemic precautions, which is all about layering multiple safety measures. This approach also gives individuals wiggle room to do some of the things that bring them joy and connection (and a paycheck), while still reducing the risk to others.

When your county is firmly in the highest risk zone — meaning Jetelina recommends not doing things like indoor dining, unmasked choir rehearsal, etc. — and you still really want (or need) to do something that goes outside of the above guidance, you can make decisions that lower your risk and help protect those around you, especially in public spaces.

According to analysis from 2020, nearly four in 10 adults in the US over the age of 18 have a higher risk of developing serious illness if they are infected with Covid-19. Four in 10 is a lot of people, and good reason to simply assume you’re going to encounter high-risk people every time you’re in public.

D’Agostino McGowan says mitigation isn’t solely about limiting the activities you engage in on the front end; your “downstream” behavior matters a lot too. For example, she says if you attend a dinner party when community transmission is high, “over the next several days, you want to be more cautious if you’re going to be in an environment where you could pass it on.”

“It doesn’t mean that you can’t do things that you enjoy, that bring you joy,” she continues. “It’s that when you’re doing them, you’re keeping who might be in the room in mind.” Keeping omicron’s shorter incubation period in mind, if you’re going to dinner indoors and a concert on a Thursday night, you should plan to mask up for church on Sunday (or to just watch the service via Zoom) and at the grocery store on Monday, and then take an antigen test on Tuesday.

Make antigen tests part of your pandemic routine

Jetelina and D’Agostino McGowan both say that rapid antigen tests are especially useful. “Rapid tests are pretty readily available now,” D’Agostino McGowan says. “So if you engage in something riskier and then you’re going to go into an environment where you don’t know the risk status of everybody, you could take a rapid test before going.”

“I don’t think enough people utilize antigen tests,” Jetelina says. “If you come back from a business trip, do an antigen test. If you go to the nursing home, certainly take an antigen test that morning before you visit. I think that’s one of the most underutilized tools of our pandemic, and I really want people to see that as a really easy tool to use to break transmission chains.” In the US, you can order free antigen tests through covidtests.gov and some state health departments, or by calling 1-800-232-0233. If you’re insured, you can seek reimbursement (up to $12 per test) from your insurer for up to eight tests per covered individual per month.

If you do utilize rapid tests, just keep in mind that they don’t always detect infections, especially in their earliest stages, and a negative test shouldn’t be treated as a license to drop all other precautions. False positives are rare, and “if you have really high transmission rates in the community, you can trust you’re positive” based on a positive result, Jetelina says. But if you’re symptomatic and testing negative in a county with high transmission, test again in 24 hours.

Instead of basing plans around calendar dates, use Covid-19 data to determine what’s safe to do

Since the beginning of the pandemic, public health officials have called on government and business leaders to avoid saying that Covid-19 restrictions will be eased on specific dates, and instead use data to determine when it’s safe to remove restrictions (and what might lead to re-implementing mandates). “There’s nothing that says ‘three weeks from now is going to be better than today,’” D’Agostino McGowan says, “other than the hope that things will just keep coming down. Rather than choosing a calendar date to change policy, it seems sensible to instead use meaningful metrics.”

Individuals, too, could manage their own expectations — and that of friends and family — by letting data inform their activities. For example, instead of planning a big indoor family gathering for a birthday in May, you could instead say that you’ll have the party once the CDC reports weekly cases at 25 per 100,000 people. If you can’t totally avoid choosing a date right now, you could instead come up with some contingency plans — booking flights that can be refunded or rescheduled, for example, and agreeing as a group that you’ll cancel if cases are more than 50 per 100,000 in the two weeks leading up to the event or there’s a new, swift-moving variant.

Doing this requires accepting that life is still not “normal” or fully within our control, which can be really, really difficult. But the more we resist that reality, the longer this pandemic will go on, and the more lives will be lost. “It’s incredibly exhausting, these last few years, and I get the frustration,” Jetelina says, “but the virus doesn’t care about how tired we are. In fact, it gives the virus an advantage if everyone’s ‘over it.’”

Think of local mandates as a starting point, not an ending point

D’Agostino McGowan uses an analogy she credits to her colleague Justin Lessler: When it comes to car safety, there are certain measures the government implements, like requiring that we all drive on the right side of the road and setting speed limits. “They’re a minimum necessary requirement in order to keep our society functioning and allow people to get around in automobiles,” she says. “And then there’s things you can layer on top of it, that will help your individual risk — both in terms of keeping you safe and keeping the people around you safe.”

That might look like buying a car with a high safety rating, making sure your tires and brakes are in good shape, and cutting down on distractions like having a pet in your lap. We should think of Covid-19 measures in a similar way.

“Sometimes I feel like when there’s a public health recommendation, like a mask mandate, it gets viewed as sufficient, or like it’s the top thing,” D’Agostino McGowan says. “Those should be viewed as the baseline to keep things going. There’s always extra things that you can do.”

“At high transmission rates, even if there is not a mask mandate, that doesn’t mean you should not have a mask on,” Jetelina says. “If you have your mask on, it will help reduce transmission to some extent. I wouldn’t underestimate the power of individual behavior. Everything helps at this point.”


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