Yes and No — It All Depends on Your Risk-Reward Analysis
The decision is all about your risk-reward equation. But if you are uncertain, you are not alone; it is the issue of the day. It may be much different if you are older, working but from home versus working in the community, a student in school, the parent of a preschooler who needs daycare, or a person with one or more of the high-risk chronic illnesses. Your risk-reward equation may also depend on who you might transmit the virus to if you should become infected — an elderly grandmother, a parent with cancer on chemotherapy. I am in my upper 70’s and live in a retirement community with people ages 65 to 107; that has a distinct impact on my risk-reward calculation; more on that later.
The number of new Covid19 cases is trending down. [True when I published this but today, June 29, 2020, it has risen quickly in a number of states largely due to lessened vigilance by individuals re social distancing and mask wearing.] A downward trend does not equate to the elimination of the coronavirus from our midst. It is still here and will continue to be here, ready to infect you or me. As the economy begins to open, as it must, we can be certain that there will be an increase in cases developing. Let us hope that most people will maintain social distancing, wash hands frequently, avoid touching their faces and, if symptomatic, quarantining themselves. If everyone or at least most everyone is faithful, then the transmission of the virus will be slow, the number of new cases limited and we will be that much closer to the time when a viable treatment and especially a vaccine becomes available.
The novel coronavirus has two key characteristics. The first is that it is easily transmissible from person to person. The second is that it causes a spectrum of illness from not apparent to severe pneumonia and death, i.e., it can be minimally or very pathogenic. Both transmissibility and pathogenicity are relevant to each individual’s decision as to what to do and when to do it.
About 50% (maybe more, maybe less) of infected people have no symptoms at all yet can still readily transmit the virus. Another 30% or so have relatively minor symptoms of cough, fever, fatigue, and perhaps some other symptoms and readily transmit the virus. About 20% develop a severe form of the disease with shortness of breath and, of those, some progress to overt pneumonia and of those some then progress to death.
Since we still don’t know the totality of asymptomatic persons, it is impossible to give an exact case fatality rate. The ~3% often cited is most likely substantially higher than the actuality. What is clear is that older people are more likely to develop severe disease and to die. Those with certain chronic illnesses (obesity, hypertension, diabetes, heart disease) are at greater risk of severe disease and the combination of chronic disease and age over 80 (a common combination) is especially dangerous.
You want to determine your risk of contracting the virus and then your risk of severe disease.
Becoming infected depends on both a source of transmission, i.e., the number of viral particles shed by the person or on an object such as a restroom faucet, and the time exposed to the source. Said differently, it depends on the total amount of viral particles you acquire and, probably, whether they are on small enough droplets to be breathed into the lungs themselves or just the throat area. An infected person who coughs or sneezes expels a huge number of viral particles whereas the same person breathing normally emits relatively few. Being near a coughing or sneezing person is high risk in any setting but when breathing normally it would matter only if you were in a crowded setting, in close proximity, and with limited air circulation and you were there for some time.
It follows that an elevator with many people would be a high risk but walking along a roadway keeping social distancing would be of minimal risk from a normally breathing but infected person. A mask worn by the infected person significantly blocks the impact of either a cough or sneeze but it would still be a moderate risk in an enclosed low air circulation setting. The risk goes down if those in exposed are also wearing a mask.
It follows that you would want to avoid that crowded elevator, a tightly packed restaurant, a small store with tight aisles. A grocery store with its large size, high ceilings, relatively wide aisles, and substantial air circulation would mean less risk for the shopper who is there for a relatively short period but more risk for the clerk who is there all day.
So-called “superspreading” events may be the most dangerous of all. Some examples — singing expels many fine droplets so being part of a church choir proved to be high risk with one member with a “cold” infected 87% of the choir members with multiple hospitalizations and some deaths. A funeral where there was much hugging and kissing led to many downstream cases. Business or other meetings such as a Biogen strategy conference in Boston where people were close together and networking spread the virus to multiple states and countries within days.
How should you put this transmission and pathogenicity information into action? It all depends on your circumstances. Mine is based on the simple fact that I am healthy but 78. At this age, my immune system is likely much less effective than ten or even five years ago so I am presumably at higher risk of severe infection should I pick it up. It would be worse if I had various chronic diseases like hypertension, obesity, diabetes, chronic lung disease, or heart failure or was a smoker. I am also mindful that it is not just me or my wife to think about but a whole community that needs to do whatever it can to keep the coronavirus off our campus. We are all in this together; if one gets infected, the risks of transmission are potentially high and the risk of severe infection among the frail and ill are very high. So, for me, the reward of going off-campus to a store, for example, is not sufficient to offset the risk to myself and others here.
Those same chronic diseases predispose younger people to severe Covid19 as well. Since one-third of the population is obese, 20 percent have diabetes and about a third have hypertension, then a substantial number (one estimate is 40%) of younger people are at higher risk if they contract Covid19. That knowledge needs to be incorporated into any middle-aged individual’s risk-reward considerations.
What about children. The vast majority that become infected have either no or minor symptoms. But there is a very uncommon but serious illness called multisystem inflammatory syndrome or MIS-C that occurs a few weeks after infection. It is rare but each parent will have to weigh the risks of sending their child back to school or camp. Certainly, being in school allows for social interaction and learning not possible with ZOOM and it allows the parent(s) to go back to work without figuring out some form of child care.
What does it mean for us: My wife and I plan to continue to be very cautious. We will use sources to bring groceries, etc. to our door. We will continue to go out for a daily walk using a mask and social distancing. We live on the second floor next to a staircase so we can avoid the elevator. Our annual physicals are due in September; for now, we plan to do it via telemedicine and skip the blood work until later.
What about a family of four with two high school students? Should they go about normal activities, get infected, and add to herd immunity? More than likely they would be among that 50% who have no symptoms or the 30% who have a relatively minor illness. On the other hand, if one or both parents can work at home, they will have an income. The high schoolers are disappointed that most summer vacation options that they planned are now closed. They are relatively content with sheltering in place although the older child just graduated (with no in-person ceremony) and greatly wants to get to his first year of college on campus come fall rather than starting on line. Will the college figure out a safe way for students to be on campus? The younger one can continue with online classes but he definitely wants to get back to the give and take of the in-person classroom.
Others have fewer options. Some need to work in the community to survive, to pay the rent, to buy food and medicines for themselves and their families. Many are employed in service industries where relatively close inter-personal contact is routine. Others work in manufacturing or meat processing plants where high numbers of workers have been infected recently. Businesses will of necessity make accommodations but risk, sometimes substantial, will still be there. And if the parent(s) are off to work, who will care for the children who have no school to go to? For many, it is a conundrum of the highest level.
You need to make your own risk-reward calculation. It will guide you to a logical decision but perhaps not the one you would have anticipated nor the one you would prefer. Meanwhile, let us hope for an effective vaccine as soon as possible.
Stephen C Schimpff, MD, MACP, is a quasi-retired internist, professor of medicine, and former CEO of the University of Maryland Medical Center. He is a graduate of Yale Medical School and is board certified in internal medicine, medical oncology and infectious diseases. He has written 6 books for the general public on medicine, health and wellness including “Longevity Decoded — The 7 Keys to Healthy Aging and co-authored Boom — Boost Our On Metabolism