Don’t Look for an On/Off Switch
The weekend weather in DC was glorious. Stumbling out my front door on Saturday morning, I squinted hard—and almost got a sunburn—picking the newspaper off the front walk.
Winter has vanished in a flash, yet most of us will need time to defrost.
My patients are asking me: How can we reconcile reentry with ongoing viral spread and variants on the rise? Can we travel and convene with loved ones when most of us haven’t gotten the vaccine?! How are people partying in Miami when I’m still living in fear?!
The answer is this: even though the sun is shining, we’ve got to get comfortable living in the gray. It’s time to assess everyday risks, mitigate risk as best we can, and make incremental changes to protect our health and wellbeing.
The pandemic won’t end in a flash. Picture an off-ramp with gradual reduction of risk over time. Similarly, the on-ramp back into life necessitates incremental change, altering our behaviors bit-by-bit while appropriately mitigating risk.
Coronavirus—just like risk in general—isn’t going away anytime soon. Eliminating it—like eliminating risk—is impossible. Coronavirus may even be with us for years to come. But that doesn't mean we can't gradually loosen restrictions and safely re-engage in life while maintaining our safety and sanity.
This is the essence of harm reduction, a public health principle of advising individuals how to mitigate risk, while acknowledging the real world conditions that may lead individuals to take some risks. It's also what primary care doctors strive to do: to meet patients where they are; empower them with facts; and help prevent disease and suffering while considering their broad human needs.
Resuming normalcy will just take practice and patience. Armed with facts, we can protect our health and wellbeing together.
Here are some facts:
The currently available vaccines are ridiculously effective at preventing death and severe disease, even against the current variants. Two weeks after you’ve been vaccinated, death and severe disease are essentially off the table, and your risk of getting COVID-19 at all is dramatically reduced. In the unlikely event of getting COVID after being vaccinated, you’d likely have a cold or mild flu.
Two weeks after vaccination, your risk of transmission also goes way down, too. The evidence is clear that vaccinated people are very unlikely to infect other people. As public health expert Monica Gandhi, MD, MPH said over the weekend, “Data on lower transmissibility (and importantly, low viral loads in the nose if you are exposed) after vaccination keeps accumulating, tilting us away from equipoise on this question at this point in March 2021.” [you can get more of Dr. Gandhi’s insights at our live Q&A tomorrow night!]
Indeed the more contagious B117 variant is circulating widely. It likely will be the dominant strain in the US, is responsible for stalling some of our progress, and is sure to cause surges when people gather this spring.
Yes, the P1 variant has been reported in New York and is indeed more contagious. But like the other variants, the vaccines work well against it.
The good news? We know exactly how to prevent the B117, B1351 and P1 variants from spreading: #1 Vaccinate! and #2 Risk mitigate! Nothing has changed here, folks! Again, the vaccines offer terrific protection against the variants, and to the extent vaccinated people can get infected with either the wild type or a variant, their symptoms are likely to be mild. Reinfections can happen in people who have recovered from COVID-19 itself—and are more likely to happen compared to people who have antibodies due to vaccination—but just like vaccinated people, immune protection from COVID antibodies turns any COVID infection into a milder illness. Masks, distancing, and avoiding indoor spaces are the surest ways to prevent unvaccinated people from getting very sick—and to prevent vaccinated people from getting a cold—from the variants.
The bad news? The more the virus spreads, the more opportunity it has to mutate in a way that could ultimately outsmart the vaccines. And indeed the virus is still spreading! For now, though, the vaccines are winning the race against viral ingenuity. With more doses on the way, and AstraZeneca now in the pipeline, we are in good shape to ultimately win this race.
The basic principles of controlling the pandemic and the intrinsic characteristics of the virus haven’t changed; HUMAN BEHAVIOR has. It is human behavior that is driving case-rate volatility. In other words, there is no mystery whatsoever as to why spring breakers in Miami are getting COVID-19 or why Michigan and New York are having a rough go. Coronavirus has a field day when we unmask or crowd together indoors, particularly in unvaccinated people and especially when more transmissible variants are in town.
Unvaccinated kids, while less likely to get sick themselves, can still carry and transmit the virus to others. As with adults, risk mitigation elements are key to prevent asymptomatic spread amongst kids. And remember, even if you think your kid “just has a cold” or “just has allergies,” they need to stay home and get tested. (This does not mean you need to fear in-person schooling which should be safe with mitigation measures in place. See my Facebook or Instagram post from earlier today.)
When kids are surrounded by vaccinated people, their risk of getting COVID also goes down. Recall that vaccinated people are unlikely to infect others. It certainly can happen—and no doubt it will—but the risk of transmission is dramatically reduced by vaccination.
Vaccinated people can be unrestricted in private. One, two, or any number of vaccinated people can mingle without restrictions or fear of death, hospitalization, and disease. The CDC (finally) acknowledged this common-sense principle earlier this month!
Unvaccinated people mixing with other unvaccinated people need to maintain full risk mitigation with the expectation that these restrictions will lift gradually once more people are immune.
Unvaccinated people mixing with vaccinated people is where risk and risk tolerance meet. It’s where the question “Can I do X?” should always be reframed as “What are the risks and benefits inherent in doing X?” It’s the reason that I cannot tell you it’s okay, for example, to host your outdoor wedding with vaccinated and unvaccinated folks under a tent. It’s about mitigating risk, knowing the facts, and prioritizing what matters to you most while protecting your and other people’s health. At the end of the day, I’m just a messenger who happened to go to med school.
My advice?
If you haven’t been vaccinated, try your darndest not to let down your guard. I’m seeing a fair amount of new COVID diagnoses as people grow weary from pandemic life. And even though monoclonal antibodies are terrific to treat early COVID, many of my patients don’t qualify to get them. If you're unvaccinated and exposed to COVID, you also could spread the virus to others—even if you don't have any symptoms yourself. Try not to get and spread COVID this close to the finish line!
Don’t forget about testing, especially with travel. If you’re not vaccinated and you’ve had any possible exposure, take a PCR test to check for asymptomatic infection. This is particularly important—as it has been for a year—before and after travel. For my patients, I suggest that we run your same-day PCR test the day before traveling and again 5-7 days after your return. (Of course the safest mode of transport for unvaccinated people is by car and only with people in the same household.) Vaccinated people can travel with a whole lot less fear. In fact, vaccinated people NEED NOT quarantine or test before or after travel given the very low risk of asymptomatic infection after you’ve been poked.
Vaccinated people only need testing if they develop symptoms. And in the case of a vaccinated person getting sick, I recommend ONLY using an antigen (or “contagiousness”) test. A PCR test is much too sensitive a test for a vaccinated person. In other words, a positive PCR test in a vaccinated person doesn’t necessarily mean that they can sicken other people. (Short story: asymptomatic infection in vaccinated people will happen—just a lot less—and isn’t necessarily clinically important. More on this another time.)
Expect reentry to be a process and not a quick pivot. Our bodies and minds have been downshifted for over a year. It's normal to feel ambivalent and anxious as we start to resume some semblance of normalcy. I wrote an opinion piece in the Washington Post about my own “FONO” (Fear of Normalcy); perhaps you can relate!
Take fear out of the driver’s seat. Instead of canceling your June wedding for fear of the variants, mitigate risk in the ways we know how. If you are mixing vaccinated and unvaccinated people, spend time outdoors if you’re able. Keep the numbers small. And if you have to be indoors with any unvaccinated people, you need to distance, mask, and keep the windows open. Risk mitigation works (if you actually do it!), and the benefits of family gatherings are unmeasurable.
Take it slow. After you have been vaccinated, take baby steps back into life. Instead of making your post-vaccination debut in a crowded bar, start with a picnic with another vaccinated friend. Bears emerging from hibernation don’t instantly put on lipstick; neither should you.
Please join me and public health expert and infectious diseases professor at UCSF, Dr. Monica Gandhi, on Facebook Live tomorrow night—Tuesday March 23, at 5 pm PT/8 pm ET—for a dose of realism from one of the smartest people I know! We will discuss vaccines, variants, and vulnerability as we face a collective recovery from the pandemic.
I will see you later this week. Until then, be well.