Updated: Apr 26, 2022
UPDATED April 26, 2022 to include CDC guidelines for monitoring COVID-19 case thresholds
From the back seat, there is a yawn, an audible sigh, and a pleading question:
"Are we there yet?"
It feels familiar to every parent and so apropos to today. We seem so much closer to our destination, a post-pandemic normal, and yet we have not fully arrived. Mask mandates are on-again/off-again, cases (depending on where you live) are up and down, and the waning of immunity looms large.
For so long we have been on red alert, Defcon 1, and now we want to return to level 5 so we can just relax. But the truth is that we need to learn to live at level 2 or 3 for the next year and possibly longer. It’s frustrating being unable to put this behind us. And while we try to stay alert but not alarmed, there are still so many questions.
As I wait for dance fitness class to start, a masked fellow dancer pulls me aside conspiratorially asking, “We dropped the mandate, why?”
Because we have the knowledge and tools to protect ourselves well, and because–in the absence of hospitals being overloaded–there is no desire to force behavior.
In the (vax-required, 10 air exchanges per hour) dance class, my approach was to not wear a mask that day because I checked the case counts in Seattle. The case counts were low, so it felt safe without a mask and the absence of a mask does make it easier to keep up with the class. Not going to class would arguably have been a riskier decision. Statistically speaking, my risk of hospitalization from a cardiovascular event (an event that might be avoided, in part, through regular aerobic activity) exceeds my risk of being hospitalized with COVID-19 at a time when case counts are low and when the vast majority of vaccinated persons are protected from severe COVID-19 even if infected.
If you are wondering how to check your local situation, you can find information on current case counts via the CDC's tracker, and indicator levels although many positive home tests are not counted. For this reason, other sources of information like wastewater surveillance (where available) might be helpful tools as you assess local risk.
If case counts or other leading indicators like wastewater surveillance hit a certain threshold, I will be masking in the gym or skipping it altogether. What threshold to use is subjective. CDC now primarily tracks hospitalizations as community indicator but once those are in the yellow or red it is too late to act. For case indicators, CDC uses anything under 200 per 100,000 population over 7 days to designate a low level of new cases; that is a reasonable threshold. To account for uncaptured positive home tests, you might double or triple case counts for your calculation. You might also look at hospital indicators or consider times when your local hospital system was crunched during the pandemic and look backward a month and apply that case level standard as a threshold for your actions.
Here are some things I think about when deciding whether to wear a mask:
Difficulty: Indoors in public, if I am not eating or exercising, I wear a mask because why not?
My Health: Whenever I feel under the weather, even if I have a negative COVID test. (I would isolate myself if I tested positive.)
Download Data-Driven's CDC Isolation and Quarantine Guide below.
Others’ Health: If I plan to be in the presence of pregnant or high-risk friends or family, I would mask in every public indoor setting for the entire week beforehand.
Agility to escape: When on airplanes, I mask. While they are well-ventilated, if you are seated beside someone sick and symptomatic, you may be stuck there for hours. And despite good inflight ventilation, boarding and deplaning are not as well ventilated. I am not concerned about the dropping of the air travel mask mandates given the current low case counts. (However, I am alarmed at the recent court ruling that the CDC has no authority for mask mandates. It represents a weakening of public health purview that has been used to keep other diseases (like Ebola) at bay and should be a tool in our toolbox for future deadly disease outbreaks.)
I can protect myself extremely well with a robust mask.
So I mask outside my home except when outdoors (great natural ventilation), eating (practical adaptation), or engaged in intense exercise when case counts are low. When they are high, I avoid restaurants and mask in all indoor public settings. If you want to mask, choose a robust mask to reduce your risk of infection. (Reminder: “robust” means an N95, KN95, or KF94 that fits snugly!) And if you want to mask in only the highest-risk settings, watch for increasing cases and hospitalizations in your area, indoor settings that are poorly ventilated, and anywhere where you might be trapped should someone start coughing or sneezing nearby.
Another common question: “So, is this over, I mean, not completely, but, you know, the bad part, right?”
I am optimistic that, at least in the US, the worst is behind us.
(To be fair, I was also optimistic a year ago before Delta and Omicron surged!) Whether through mass vaccination or a massive number of infections, most Americans have some immunity that will most likely protect them from a severe course of COVID-19. That immunity will fade over time. We are not sure how long the timeline is until waning immunity translates into the risk of severe illness. We also do not yet know how this timeline might differ for immunity from vaccine versus infection, but we do know it wanes and wanes more quickly as people age.
Until we vaccinate the world, variants will continue to happen. But vaccinating the world is not easy— even with vaccine supplies donated to low-income countries, the infrastructure to deploy mass vaccination is not in place in many parts of the world. Each time the virus replicates, there is the possibility of replication error or mutation. While the vast majority of errors will have no impact on the course of the pandemic, each error has the potential to add a mutation that enables the virus to evade our vaccines. This results in a situation that, in the context of abundant replications and many evasive mutations, could mean the spread of a dangerous variant for which past infection or vaccination may be inadequate. With a rapidly replicating and shape-shifting virus, this threat is ever-present.
This virus has brought many surprises and there are likely more ahead. Barring an unexpected twist, I expect that as COVID starts along the path to endemicity (where a disease is present at relatively steady levels), we will see surges and variants along the way; some of these may be concerning enough to motivate a return to behaviors that helped us reduce transmission over the past two years.
“Aren’t we all going to get this virus, I mean, why should I even try to avoid it?”
Avoiding COVID as long as possible still makes sense.
We are getting better at treating infections, but have more progress to make. With the antiviral drug Paxlovid increasingly available, the Biden administration has set up a Test to Treat strategy where high-risk individuals who test positive and qualify can get an oral antiviral without delay. Medications like Paxlovid have the potential to wipe out an infection just as it gets started. However, Test to Treat is not available nationwide; we need to create an all-inclusive Test to Treat capacity before the next surge hits.
You cannot just “get it over with”. Unlike diseases like measles, COVID-19 does not bring sterilizing (lifelong) immunity.
Long COVID is real and debilitating in many. If you know anyone with Long COVID, you know how quickly life can change from athletic and engaged to lethargic and sickly. We do not fully understand this disease, but we know its devastation. Until we have better control over this virus and understand how to more effectively treat what is called in medical terms “post-acute sequelae of COVID” (PASC), it remains wise to avoid it.
Viruses are spooky! A virus today can cause issues years from now. And not just Long COVID. For instance, maternal viral infections during pregnancy have been linked to both onsets of schizophrenia and narcolepsy in offspring. The Epstein Barr Virus is a risk factor for nasopharyngeal cancer and the Hepatitis B Virus for liver cancer. The time between infection and these impacts is long and we simply don’t have much history with COVID. While we may not succeed in avoiding it entirely, delaying infection might help defer long-term sequelae.
“So, my mom asks, ‘I qualify for the 2nd booster. What do you think, should I get it? And is now the right time?'"
For this discussion, I am not talking about a third shot for J&J recipients, as they qualify based on concerns about the effectiveness of their original vaccine. I am specifically discussing a fourth shot (2nd booster) for those aged 50+ who have had three mRNA vaccine shots.
Compared to those with only a first booster, an Israeli study estimated that a second booster appears to reduce COVID-19 mortality by up to 78% in those aged 60 and over (this result was very age-specific).
That’s an amazing result, right? Yes, but with caveats:
The study, from Israel, was not a random sample of the population, but rather, took volunteers. In a scientific study, this difference may create misleading results because, for example, volunteers for a fourth shot might be more health-conscious and/or more risk-averse than the general population. If so, they are already at a decreased risk for severe COVID by (1) engaging in less risky behaviors (e.g., smoking) and (2) having fewer chronic diseases (like diabetes).
Although the current second booster is FDA-approved for Americans aged 50+, the study did not include people under the age of 60.
Protection may be short-lived. The study covered a period of only 40 days, leaving unanswered the question of how fast protection fades and if a booster should be timed to coincide with an emerging surge or a sneaky variant.
"So if I get a second booster, when will it help the most?"
They say you “can’t time the market” but can you time a vaccine booster? Maybe. But there are a lot of factors to consider. Like timing the market, timing a booster dose is not without risk. If you wait too long, you could miss out on essential protection. And there is mounting evidence for booster protection waning considerably after three months, though more data are still needed. If you get a booster now and another is not available for four to six months, you might be more vulnerable if we see a summer or fall surge. That said, unlike the market, a surge or variant is likely to be preceded by some leading indicators (wastewater detection, increased case counts, a higher burden of “breakthrough” infections).
The ACIP (Advisory Committee on Immunization Practices) is the public health body that provides advice and guidance regarding the use of vaccines for the control of vaccine-preventable diseases. ACIP's clinical guidance notes that people might consider delaying a second dose if they are “hesitant about getting another recommended booster dose in the future, as a booster dose may be more important in the fall and/or if a variant-specific vaccine is needed.”
There is no right answer here so talk to your doctor about what is best for you as there is plenty to consider and discuss as you find your answer.
“So are we there yet?”
Yes! We have plentiful masks that offer excellent protection.
Yes! We have a good supply of vaccines that dramatically reduce the risk of severe COVID and more modestly reduce the risk of Long COVID.
Yes! We have drugs like Paxlovid that have the potential to stop the virus in its tracks if taken early enough.
We have come so far,
but are not quite at the destination of Defcon 5. But we can focus and prepare for the journey ahead.
Be informed, aware, and remember to expect some bumps in the road ahead:
Seasonality: We don’t understand COVID’s seasonality and transmission patterns well yet but watch the south (in particular Florida) for a late summer surge and the rest of the country for a Thanksgiving to New Year’s surge and be ready to pivot if need be. Increases may be more like an uptick than a surge but a surge is possible and will depend on many factors, such as level of population immunity, immune durability, emergence and properties of variants, and worldwide transmission patterns.
Too little global immunity: Much of the world is not equipped to distribute vaccines due to inadequate health infrastructure. Areas with low vaccination levels will be places where the virus replicates and variants are more likely to emerge. Some of these variants could threaten the immunity that vaccines and natural illnesses have created to date.
“Antigenic shift”: As they say, “shift happens”. Whether it is an antigenic shift or antigenic evolution, antigens will change and variants will emerge. We will likely need to tweak our vaccines to deal with them. And on an exciting scientific note, we can do this pretty easily with the mRNA technology and this effort is already underway. New vaccines need updating with mRNA that can instruct our cells to build proteins that look more like emerging variants. Stay tuned for a future blog post on the vaccines being developed to cover several variants!!
As we move forward...
The COVID pandemic has been a journey and it's not over yet. But, as we move forward, there is much good that came out of this pandemic in terms of the amazing speed of science, the use of scientific technologies (like mRNA), and therapeutics (like Paxlovid) that are certain to save lives from COVID-19 and other threats long after this pandemic has settled into a steady state.