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This site shows data for highest COVID risk areas in the US. This can be used to weigh the risks of going outside the home.

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Covid Act Now has real-time COVID data and risk level for your community. See how your community is doing at covidactnow.org.

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Updated Regularly: Johns Hopkins University COVID-19 Map 

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Updated Regularly: Johns Hopkins University COVID-19 Map 

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Johns Hopkins Coronavirus Resource Center

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COVID-19 Map - Johns Hopkins Coronavirus Resource Center

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Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

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COVID-19 #Coronavirus latest data visualized.
You are welcome to use these graphic in any way you please.

Created by David McCandless, Omid Kashan, Fabio Bergamaschi, Dr Stephanie Starling, Univers Labs, Nueker, Tom Evans
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COVID-19 #CoronaVirus Infographic Datapack - Information is Beautiful

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Updated daily, now with global vaccination stats

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Up-to-date values for Rt - the number to watch to measure COVID spread.

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Johns Hopkins Coronavirus Resource Center

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Johns Hopkins University is hosting a free, publicly available course titled Understanding the COVID-19 Pandemic: Insights from Johns Hopkins University Experts. This course is set up as a series of short modules to explore the COVID-19 pandemic. Registration is not required.

The modules build on each other. The course begins with a discussion of the virus that causes COVID-19 and works its way to the pandemic's broader implications for society.

This course features original content that was created after the imposition of social distancing measures.
Upon completing this course, you will be able to:

Describe characteristics of the COVID-19 disease, including how it is diagnosed and treated

Understand the development of the COVID-19 pandemic, and emerging trends throughout the world

Discuss societal challenges raised by COVID-19 and opportunities to address them

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Johns Hopkins University is hosting a free, publicly available course titled Understanding the COVID-19 Pandemic: Insights from Johns Hopkins University Experts. This course is set up as a series of short modules to explore the COVID-19 pandemic. Registration is not required. The modules build on each other.

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Vaccinated and unvaccinated people are getting more lax with behavior at a time when vigilance really matters.

CSA Images / Designer 29 / Getty / Katie Martin / The Atlantic

A few weeks ago, my partially vaccinated partner and my wholly unvaccinated self got an invitation to a group dinner, held unmasked and indoors. There'd be Thai food for 10, we were promised, and two über-immunized hosts, more than two weeks out from their last Moderna doses. And what about everyone else? I asked. Would they be fully vaccinated, too?

Well, came the response. Not really. Some would be, some wouldn't. But it had been so long-weren't we close enough?

The answer was of course no, and my partner and I ended up staying home. But as the weeks wear on, I'm having more and more of these conversations with people who are struggling to navigate the new social calculus of a partly vaccinated world. Even as infection rates tick up again, people are bending, stretching, and breaking the rules governing how they should act around others: A recent Gallup poll showed that Americans' vigilance about distancing and avoiding public places seems to be slackening, regardless of their immunization status. Slowly but surely, we're losing our grip.

To be clear, we have reason for optimism. Vaccination rates are also rising, and according to the latest estimates, the currently cleared shots are extraordinarily effective at preventing not just symptomatic disease, but asymptomatic infections-key to slowing the virus's often-silent spread. In recent weeks, the CDC has green-lit fully vaccinated people to skip post-exposure quarantines; mingle with one another in small groups, indoors and unmasked; visit unvaccinated, low-risk people under limited circumstances; and, now, travel safely within the United States. With less than 20 percent of the country fully vaccinated, the agency is quite understandably moving with caution, and hasn't yet changed its stance on whether vaccinated people should wear masks in public (yes) or gather in medium- and large-size groups (no).

Recommended Reading

But across the country, states are rushing to lift mask mandates, tolerance for physical distancing is flagging, and vaccinated people are amending the new guidelines as they see fit. Some, like our would-be dinner-party hosts, are planning mixed-vaccination events, and pushing the boundaries of what makes a gathering "small." Others are holding birthday bashes, or starting to creep back to in-person work. People are also shaving time off the two-week period that the CDC advises waiting after the final shot, so that immunity can mature. "What difference is a few days going to make?" a friend asked me the other day.
Read: The false dilemma of post-vaccination risk
Amid all the fudging, that sentiment is starting to become a constant refrain: Really, what's the harm?

The harm is, frankly, mathematical. Over time, our vaccine cheat days start to add up. It might truly be innocuous for a few people to cut a couple of corners on occasion. But eventually, a series of flubs will allow exposures, which will in turn beget disease. Our shortcuts also signal to others that it's okay to chill out when it is very much not.

Now is not the time to relax-quite the opposite. "We're so close to the end that we should be extra careful right now," Julie Downs, a psychologist and behavioral scientist at Carnegie Mellon University, told me. The problem is, our lapses don't just slow us down. They set us back, in the same way that repeatedly opening an oven door will prolong the time it takes to bake a cake (and, at worst, make your delicious dessert collapse). Having made so much progress, we risk a lot with our impatience. And right now, we're in serious danger of botching our grand pandemic finale.

The CDC can't be expected to lay out every possible social scenario that a vaccinated person might encounter. But public-health officials do have the tough job of tweaking guidance based on new data on vaccine effectiveness. Wobbly rules are harder to communicate and follow; even CDC Director Rochelle Walensky seemed to waffle last week while discussing how effectively inoculations thwart infection and the risks of post-vaccination travel.

Unfortunately, humans have a tendency to spin ambiguity into the most favorable outcome available, says Uma Karmarkar, a behavioral-economics expert who studies decision making at UC San Diego. Any squishiness in wording can provide a loophole for people to pick at, or to massage into a more convenient shape. Saskia Popescu, an infection-prevention expert based in Arizona, told me she's already noticed people deriving false equivalences from the agency's guidelines: "People figure, If I can get together with another household that's unvaccinated, why can't we do large meetings? "

Many of these decisions, while well intentioned, will create a patchwork of post-vaccination behaviors, a lot of which will be risk miscalculations. "If I'm the one left to generalize, I'm going to use intuition," Downs said. "So if I can do this, surely I can do this -maybe I don't see it as a step toward the risky, but as a step toward the side." Some people who believe that they've behaved responsibly this past year might feel more impervious to the virus, and cut themselves more slack, Karmarkar told me. A sense of exceptionalism, she said, makes it easy to say, "Well, an intimate gathering might be eight to 10 for most people, but we're extra careful, so 12 or 14 is probably fine." Even people who say they plan to get vaccinated but haven't yet appear to be loosening up ahead of schedule, according to the Gallup survey-perhaps because, for some people, the wait is becoming too much to take.

The post-vaccination cohort might also be subtly signaling to others that behavioral change is expected, and good. Having a ton of vaccinated friends who are starting to hang out and shed their masks might be renormalizing old habits for those who expect their shots soon.

The rash of rule-breaking and early restriction-lifting can't be helping either, Karmarkar told me. "People are out doing stuff," she said. "Instagram is starting to look like it used to." That's probably sapping the motivation of people who have been white-knuckling it all year. "They think, It's not fair," she said. " If no one else is being good, why am I at home? "

There are, of course, some people who have decided to double down on their vigilance in recent months, even after getting their vaccines. Popescu grimly describes people's post-inoculation behavior as almost bimodal-super strict or loose, with practically no in-between.
Read: Vaccinated people are going to hug each other.
Gravitating toward extremes might be our way of grappling with new ambiguities that the vaccines have introduced. Just as infection can be asymptomatic, vaccination protection, too, is invisible. There's no way to tell if the maskless people strolling together in the park are letting their guard down because they're vaccinated, or if they're just sick of wearing cloth on their face. (Popescu, who is fully vaccinated, told me that's why she's been keeping her mask on in public: "If I take it off, they just see a person normalizing less safe behavior.")

Risk is easier to calculate when it's visible and self-contained-taking a recreational drug, bungee jumping off a cliff. This past year, we've been grappling with a far more unwieldy threat, Kenneth Carter, a psychologist at Emory University, told me. "It would be easier if it were zombies," he said. Our frame of reference is also shifting all the time, Downs told me. At the beginning of the pandemic, the situation was growing riskier, shifting us down from our baseline of "normal." Now we're getting signals that things are improving. The vaccines have injected hope into the conversation; they're a tool that is raising the amount of safety we're working with day to day. This new direction is creating a small illusion: Simply hearing "It's getting safer" can inadvertently punt people into what Downs calls a quantum shift, into "It's safe," she said. The mindset of "better" is easy to conflate with "okay" or even "good."

The point of this is not to underestimate the vaccines. They're excellent, extraordinary, expectation-shattering, and already protecting millions of people from many of the most serious consequences of COVID-19. But we can't afford to overestimate them, either, and we're still defining their limits when it comes to blocking disease and infection in real-world circumstances, as the virus they defend against continues to change. As good as these shots are, they can only dial down risk, not eliminate it-more like coats of flame retardant than an impenetrable firewall. Exposure and risk, which occur on a spectrum, also go hand in hand; even the best inoculations will be of little use to people who choose to stroll straight into a viral conflagration.

Experts told me it's worth keeping a few key things in mind if we intend to truly make this next chapter of the crisis our last. For starters, we can't take the pandemic's endgame for granted. Surging cases threaten a vicious cycle: More infections mean more opportunities for the virus to move between hosts and mutate, and potentially further elude our defenses. To forestall that possibility, we still have to consider our collective risk, not just our risk as individuals. Carter stressed the importance of acknowledging how far we've come-not just how far we have left to go. "My message right now is 'I'm so proud of all the sacrifices you've made already,'" he told me. "'Just hold on a little longer.'"
The Atlantic's COVID-19 coverage is supported by a grant from the Chan Zuckerberg Initiative

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Vaccinated and unvaccinated people are getting more lax with behavior at a time when vigilance really matters. A few weeks ago, my partially vaccinated partner and my wholly unvaccinated self got an invitation to a group dinner, held unmasked and indoors.

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This week, the C.D.C. acknowledged what scientists have been saying for months: The risk of catching the coronavirus from surfaces is low.

A hotel room in Long Beach, Wash., being fogged with sanitizer. "There's really no evidence that anyone has ever gotten Covid-19 by touching a contaminated surface," one researcher noted. Credit... Celeste Noche for The New York Times

When the coronavirus began to spread in the United States last spring, many experts warned of the danger posed by surfaces. Researchers reported that the virus could survive for days on plastic or stainless steel, and the Centers for Disease Control and Prevention advised that if someone touched one of these contaminated surfaces - and then touched their eyes, nose or mouth - they could become infected.

Americans responded in kind, wiping down groceries, quarantining mail and clearing drugstore shelves of Clorox wipes. Facebook closed two of its offices for a " deep cleaning." New York's Metropolitan Transportation Authority began disinfecting subway cars every night.

But the era of " hygiene theater" may have come to an unofficial end this week, when the C.D.C. updated its surface cleaning guidelines and noted that the risk of contracting the virus from touching a contaminated surface was less than 1 in 10,000.

"People can be affected with the virus that causes Covid-19 through contact with contaminated surfaces and objects," Dr. Rochelle Walensky, the director of the C.D.C., said at a White House briefing on Monday. "However, evidence has demonstrated that the risk by this route of infection of transmission is actually low."

The admission is long overdue, scientists say.

"Finally," said Linsey Marr, an expert on airborne viruses at Virginia Tech. "We've known this for a long time and yet people are still focusing so much on surface cleaning." She added, "There's really no evidence that anyone has ever gotten Covid-19 by touching a contaminated surface."

During the early days of the pandemic, many experts believed that the virus spread primarily through large respiratory droplets. These droplets are too heavy to travel long distances through the air but can fall onto objects and surfaces.

In this context, a focus on scrubbing down every surface seemed to make sense. "Surface cleaning is more familiar," Dr. Marr said. "We know how to do it. You can see people doing it, you see the clean surface. And so I think it makes people feel safer."

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A "sanitization specialist" at an Applebee's Grill and Bar in Westbury, N.Y., wiping down a used pen last year. Restaurants and other businesses have highlighted extra cleaning in their marketing since the pandemic began. Credit... Hiroko Masuike/The New York Times

But over the last year, it has become increasingly clear that the virus spreads primarily through the air - in both large and small droplets, which can remain aloft longer - and that scouring door handles and subway seats does little to keep people safe.

"The scientific basis for all this concern about surfaces is very slim - slim to none," said Emanuel Goldman, a microbiologist at Rutgers University, who wrote last summer that the risk of surface transmission had been overblown. "This is a virus you get by breathing. It's not a virus you get by touching."

The C.D.C. has previously acknowledged that surfaces are not the primary way that the virus spreads. But the agency's statements this week went further.

"The most important part of this update is that they're clearly communicating to the public the correct, low risk from surfaces, which is not a message that has been clearly communicated for the past year," said Joseph Allen, a building safety expert at the Harvard T.H. Chan School of Public Health.

Catching the virus from surfaces remains theoretically possible, he noted. But it requires many things to go wrong: a lot of fresh, infectious viral particles to be deposited on a surface, and then for a relatively large quantity of them to be quickly transferred to someone's hand and then to their face. "Presence on a surface does not equal risk," Dr. Allen said.

In most cases, cleaning with simple soap and water - in addition to hand-washing and mask-wearing - is enough to keep the odds of surface transmission low, the C.D.C.'s updated cleaning guidelines say. In most everyday scenarios and environments, people do not need to use chemical disinfectants, the agency notes.

"What this does very usefully, I think, is tell us what we don't need to do," said Donald Milton, an aerosol scientist at the University of Maryland. "Doing a lot of spraying and misting of chemicals isn't helpful."

Still, the guidelines do suggest that if someone who has Covid-19 has been in a particular space within the last day, the area should be both cleaned and disinfected.

"Disinfection is only recommended in indoor settings - schools and homes - where there has been a suspected or confirmed case of Covid-19 within the last 24 hours," Dr. Walensky said during the White House briefing. "Also, in most cases, fogging, fumigation and wide-area or electrostatic spraying is not recommended as a primary method of disinfection and has several safety risks to consider."

And the new cleaning guidelines do not apply to health care facilities, which may require more intensive cleaning and disinfection.

Saskia Popescu, an infectious disease epidemiologist at George Mason University, said that she was happy to see the new guidance, which "reflects our evolving data on transmission throughout the pandemic."

But she noted that it remained important to continue doing some regular cleaning - and maintaining good hand-washing practices - to reduce the risk of contracting not just the coronavirus but any other pathogens that might be lingering on a particular surface.

Dr. Allen said that the school and business officials he has spoken with this week expressed relief over the updated guidelines, which will allow them to pull back on some of their intensive cleaning regimens. "This frees up a lot of organizations to spend that money better," he said.

Schools, businesses and other institutions that want to keep people safe should shift their attention from surfaces to air quality, he said, and invest in improved ventilation and filtration.

"This should be the end of deep cleaning," Dr. Allen said, noting that the misplaced focus on surfaces has had real costs. "It has led to closed playgrounds, it has led to taking nets off basketball courts, it has led to quarantining books in the library. It has led to entire missed school days for deep cleaning. It has led to not being able to share a pencil. So that's all that hygiene theater, and it's a direct result of not properly classifying surface transmission as low risk."

Roni Caryn Rabin contributed reporting

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Has the Era of Overzealous Cleaning Finally Come to an End?

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This week, the C.D.C. acknowledged what scientists have been saying for months: The risk of catching the coronavirus from surfaces is low. When the coronavirus began to spread in the United States last spring, many experts warned of the danger posed by surfaces.

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The vaccines are phenomenal. Belaboring their imperfections-and telling people who receive them never to let down their guard-carries its own risks.

Epidemiologist and professor at Harvard Medical School

Yonatan Sindel / Flash90 / Redux

When Americans began receiving coronavirus vaccines last month, people started fantasizing about the first thing they'd do when the pandemic ends: go back to work, visit family, hug friends. But the public discussion soon shifted. One news article after another warned about everything that could go wrong: Protection isn't immediate; vaccinated people can still transmit the virus; vaccinated people might get mild infections that could become chronic; vaccines might not work as well against new coronavirus variants. "COVID-19 Vaccine Doesn't Mean You Can Party Like It's 1999," one headline admonished. Can vaccinated people at least hang out with one another? Nope, masks and distancing are still required. "Bottom line," another article concluded ominously: "You will need to wear a face mask after you're vaccinated until COVID-19 cases become nearly nonexistent."

Although scientists are still learning about how much the two government-approved vaccines reduce transmission of the coronavirus, the evidence shows that their efficacy against disease is phenomenal. Although not zero-risk, close contact between two people is safer if one has received a vaccine, and safer still if both are vaccinated. For this reason, public-health experts elsewhere in the world are emphasizing hope. In a new social-media campaign, health officials from across the European Union stress that vaccination will help people get their lives back. "I'll do it to protect my father and organise a big family weekend get-together," declares Belgium's chief scientific adviser. "I did it because I want us to live normally again," says the chief coronavirus adviser in Romania.

Recommended Reading

But in the United States, the prevailing message is that, because vaccines aren't perfect, people who have received them shouldn't let down their guard in any way-not even at gatherings with just a few other vaccinated people. "Based on science and how vaccines work, it certainly is likely that [such a gathering] will end up being lower-risk," a pharmacologist from Johns Hopkins University told The Washington Post. "But right now, we just don't know." Government officials are no more upbeat. In response to the question of whether a vaccinated person needs to continue taking precautions, the CDC states that "not enough information is currently available" to say when- or even if -it will stop recommending the use of masks and distancing.
Brendan Nyhan: How to build trust in the vaccines
The message that vaccines aren't 100 percent effective in preventing disease, and that the data are still out on how much they reduce transmission, is an accurate and important one. Risk-mitigation strategies are needed in public spaces, particularly indoors, until more people are vaccinated and infections wane. But not all human interactions take place in public. Advising people that they must do nothing differently after vaccination-not even in the privacy of their homes-creates the misimpression that vaccines offer little benefit at all. Vaccines provide a true reduction of risk, not a false sense of security. And trying to eliminate even the lowest-risk changes in behavior both underestimates people's need to be close to one another and discourages the very thing that will get everyone out of this mess: vaccine uptake.

From the beginning, many government officials and media commentators have made a habit of blaming the pandemic on the public's misbehavior. Concerns that vaccinated people will start throwing " rona raves" or exhibit other irresponsible behavior therefore come as no surprise.

But people are likely to behave far more cautiously. Survey data from Great Britain suggest that a large majority of people there plan to continue following public-health guidelines after vaccination-albeit, for some, less strictly. Nearly a third of epidemiologists who responded to a New York Times survey late last year said they would be comfortable returning to more activities of daily life after vaccination, but these are likely to be baby steps, not leaps. Maybe a grandparent will decide to hold a grandchild for the first time in a year. Maybe people will send their kids back to school, fly to visit aging loved ones, socialize with a few other vaccinated friends, try to go on a date or two. Even if those decisions are unlikely to cause harm, they appear selfish if the goal is to eliminate the tiniest risk of spreading the coronavirus. But health is more than the absence of disease.

The question of how vaccines change people's individual and collective risk-benefit calculus has implications beyond whether vaccinated adults can have drinks together inside one of their homes. It also affects decisions about how crucial parts of society will function: whether unvaccinated children can go back to school after teachers are vaccinated, or whether an unvaccinated person can visit a vaccinated elderly relative in a nursing home. Those discussions suffer when experts and other commentators belabor the potential pitfalls of vaccines out of fear that some people will abuse their freedom.
Read: The next phase of vaccination will be even harder
The anxiety about how people might behave when they are less afraid is all too familiar to those of us who work on HIV prevention. When the medication Truvada was approved in 2012 as preexposure prophylaxis (or PrEP)-a daily pill to prevent HIV-it sparked a debate about what public-health experts call risk compensation. The worry was that people who felt protected by PrEP would use condoms less often-potentially negating the medication's effect and increasing their risk of contracting other sexually transmitted infections. PrEP has turned out to be far more effective at preventing HIV than condoms are, assuaging some of those concerns. But the emphasis on risk compensation was not solely about infection. True to America's puritanical roots, it also reflected moral judgments about condomless sex; PrEP was described as a " party drug" and its users were called " Truvada whores." That stigma has been profoundly detrimental: Uptake of PrEP remains low, and some clinicians still hesitate to prescribe it, especially to people who use condoms inconsistently and therefore need the medication most.

Moral panic about risk compensation is misguided; it obscures the reasons some people change their behavior and what they could lose by not doing so. For some, the ability to have more physical intimacy is the whole point of PrEP-just as it is, for some, the whole point of birth-control pills. Likewise, some people are eager to get a coronavirus vaccine because they feel an intense need to be close to others. That's why exhortations about unwavering vigilance after vaccination may have unintended consequences-not just dissuading vaccine uptake but also sapping the public's hope. "The truth is that if I thought I was going to be living the way I'm living now for another 10 months," the New York Times columnist Michelle Goldberg tweeted about the dour vaccine messaging, "I'd probably give up completely."

The early weeks of a sluggish vaccine rollout have given people many reasons for discontent. One is that people with the greatest need for protection have not necessarily been first in line for the shots. Prioritization plans have taken racial equity into account, but only nominally: Black and Latino people, who are at the highest risk of infection, have been the least likely to be vaccinated. Seeing those inequities, some commentators have suggested that vaccinated people should patiently wait to expand their lives until everyone can, just as people whose dinner arrives first at a restaurant are expected to wait to eat until all of their companions have been served. This bit of etiquette has a certain fairness to it. Vaccine FOMO is real. But I will feel no joy if vaccinated people wait to hug their grandkids until I am vaccinated, nor will that get me-or those at higher risk than I am-vaccinated any faster. Self-deprivation will not, in itself, prevent infection. And no one enjoys letting their food get cold.

The pandemic is a bedeviling problem that vaccines alone cannot immediately solve. As long as the supply of doses remains limited and the coronavirus continues spreading at high rates across the country, public-health officials need to communicate that the greatest risk reduction comes from a combination of measures that includes good masks, distancing, and ventilation. And officials need to enable the public to take those measures-while recognizing that staying infection-free is not the only thing that matters to people. Public health isn't merely the business of saying no; addressing people's unmet needs is an essential part of the job, even during a pandemic. "I did it to enjoy life," Malta's top coronavirus adviser proclaims as part of the EU's vaccination campaign.
Read: Go ahead, share your vaccine selfie
The vaccines are poised to deliver what people so desperately want: an end, however protracted, to this pandemic. Everyone's focus needs to be on getting the highest-risk people vaccinated as quickly as possible, not on faulting vaccinated people for a few unmasked hugs.

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early weeks of a sluggish vaccine rollout

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Vaccinated People Are Going to Hug Each Other

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The vaccines are phenomenal. Belaboring their imperfections-and telling people who receive them never to let down their guard-carries its own risks. Epidemiologist and professor at Harvard Medical School When Americans began receiving coronavirus vaccines last month, people started fantasizing about the first thing they'd do when the pandemic ends: go back to work, visit family, hug friends.

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The 6-foot social-distancing rule is based on nearly 80-year-old science. Scientists at MIT and Oxford have created a traffic-light system to use instead.

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The 6-foot rule for social distancing is based on science that's 80 years old. Researchers say it's an antiquated way to think about how viruses move through the air. Instead, we should be considering many facets of an interaction: where it takes place, how long it lasts, and whether it's going to be loud.

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Many people hope that getting a Covid-19 vaccine will mark an immediate return to normal: no more masks, no more distancing, safe indoor dinner parties and big hugs with friends.

The reality is more complicated. For now, people who have gotten their shots must navigate decision-making in a world where the vaccinated and unvaccinated will coexist for months, even within the same household.

So what should and shouldn't you do? The U.S. Centers for Disease Control and Prevention issued guidelines Monday. Fully vaccinated people can gather indoors with others who are also fully vaccinated without taking extra precautions, the CDC said. And vaccinated people may gather with one other unvaccinated family without masks and distancing as long as the unvaccinated members are healthy and aren't at risk for developing a more serious case of Covid-19. But the CDC urged fully vaccinated people to continue taking precautions in public, and in medium or large private gatherings.

"There are some activities that fully vaccinated people can begin to resume now in the privacy of their own homes," said CDC director Rochelle Walensky. "Everyone-even those who are vaccinated-should continue with all mitigation strategies when in public settings."

The CDC and most experts agree that until we are closer to herd immunity-when a substantial majority of the population is protected through vaccination or natural infection so the virus can't spread easily-mask wearing, social distancing and avoiding crowded, indoor gatherings should be standard practice in public spaces. The CDC guidelines note that evidence increasingly suggests that vaccinated people are potentially less likely to transmit the virus through asymptomatic infections, but there are also outstanding questions on the duration of the vaccines' protection and the effect of emerging variants.

"Particularly for these several months where immunization coverage is low, we're still learning about the variants, and we still need to know about this onward transmission, the public health messaging really is to maintain these behaviors," says Chris Beyrer, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health. "Until we get out of this. We're not out of it yet."

Here are recommendations from scientists on how to assess the risks.

Is it OK for vaccinated people to meet with other vaccinated people?

The CDC guidelines and experts agree that once fully vaccinated-at least two weeks after your second dose of the Pfizer or Moderna vaccines or the single Johnson & Johnson shot-it's safe to meet indoors with other fully vaccinated people without masks or distancing.

Gathering with other vaccinated people is "scientifically very safe," says Paul E. Sax, clinical director of the division of infectious diseases at Brigham and Women's Hospital in Boston. Nothing is 100% effective but "gathering with other vaccinated people is pretty darn close," he says.

"I don't think people should run to a crowded bar where people are shouting at each other," he says. "But the kind of socializing that is part of human nature and that has been put on hold for a lot of people-that can resume."

The larger the group, the riskier the interaction, because you can't verify that everyone is vaccinated and you don't know what their exposures are, says Leana Wen, an emergency physician and public health professor at George Washington University in Washington, D.C. "I'm talking one other couple or maybe two other couples at most," says Dr. Wen. The CDC guidelines say precautions such as wearing masks and social distancing should be taken for medium and large gatherings despite the vaccination status of individuals.

Monica Gandhi, an infectious disease physician and professor of medicine at the University of California, San Francisco, is less conservative, saying there should be no limits on the size of gatherings for fully vaccinated individuals. "They can have dinner parties. They can go to restaurants. They can go to the movies," she says. But she notes that even vaccinated people will need to follow mask and distancing requirements in those public settings until we reach herd immunity.

What if the adults are vaccinated but the kids aren't?

There is currently no authorized vaccine for children and adolescents under 16 years old. "This is going to be one of those issues that families are going to have to grapple with and be prudent about," says Dr. Beyrer.

The CDC guidelines say people who are fully vaccinated can visit indoors with one other unvaccinated household without wearing masks or maintaining social distance if the unvaccinated people are at low risk for severe Covid-19.

There's a significant difference between young children and adolescents or teens in terms of both transmission of the virus as well as getting the disease, Dr. Sax says. Adolescents get and transmit Covid-19 similarly to young adults, while younger children don't get symptomatic disease as often and don't appear to transmit as much. "Every family and every group of friends is going to make decisions based on their own risk tolerance," says Dr. Sax.

Immunocompromised individuals and their families should be more careful, as vaccines in general can be less effective in them, says Dr. Sax.

Dr. Wen says she recommends that families continue to take precautions during playdates when the adults are vaccinated but the kids aren't. "If those families are also associating with other families, that's a risky scenario that I would not recommend at this time," says Dr. Wen of indoor gatherings. "They could be an asymptomatic carrier who then spread it to their children. And if the children are in school or daycare, there could be additional spread from that."

Can a fully vaccinated family meet with unvaccinated people indoors without masks?

The CDC guidelines say yes, they can, as long as the unvaccinated people are from one household and have no risk factors that put them at risk of developing severe Covid-19.

Gregory Poland, director of the Mayo Vaccine Research Group in Rochester, Minn. says this could be potentially risky because unvaccinated people may not disclose their medical risks and may not even be aware they have any. There's not a lot of data of vaccine efficacy among people who are very elderly, on chemotherapy, or immunocompromised, he notes.

What is the latest on whether vaccinated people can spread the virus to unvaccinated people?

Recent studies found that vaccination reduced asymptomatic infection more than 80% when compared to unvaccinated individuals and nasal viral loads are low and potentially noninfectious, says Dr. Gandhi. But other experts say the evidence is preliminary and more conclusive evidence is needed. And new variants raise additional questions about vaccine effectiveness.

What activities should I prioritize after I get vaccinated?

Schedule any routine medical and health appointments that you've been putting off, Dr. Wen says. Get your colonoscopy, mammogram or dental cleaning. Schedule an elective surgery. "Anything like that you should resume because you are well protected," says Dr. Wen.

What about travel?

The CDC guidelines didn't update travel recommendations. Once you are vaccinated, traveling is lower risk, says Dr. Wen, as is staying at a hotel or going to restaurants, so long as you follow safety protocols. But continue to be cautious about how you meet with people once you arrive at your destination, she says, particularly if they aren't vaccinated or live in an area that has high transmission rates.

Is it safe for my elderly parents to travel for a visit?

Dr. Wen says fully vaccinated people, including healthy grandparents, should be encouraged to travel as long as they take the appropriate precautions, such as wearing masks when in public. "The travel itself is very low risk," says Dr. Wen. "If they follow precautions like wearing a mask, the risk of them contracting the coronavirus and passing it on to the rest of the family is extremely low and the benefit is huge. People are eager to see their families."

But still weigh the specifics of your situation. If you have an unvaccinated older teen and a frail, elderly grandparent, consider more precautions, says Dr. Poland.

Which activities are lower and higher risk, even after vaccination?

Vaccinated individuals can feel comfortable when doing quiet indoor activities where people are generally still required to be masked and distanced, such as visiting an uncrowded museum, says Dr. Sax. Outdoor activities are even safer.

Higher-risk situations include indoor dining, bars, gyms and houses of worship, where people are singing and talking. "We don't want to push the limits of what the vaccines can do before case numbers drop," says Dr. Sax. He and his physician wife are both fully vaccinated but won't dine in restaurants until case numbers and hospitalizations are significantly lower, he says.

-Betsy McKay contributed to this article.

Write to Sumathi Reddy at sumathi.reddy@wsj.com

Copyright ©2020 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8

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What You Can and Can't Do if You've Been Vaccinated: Travel, Gatherings, Risk Factors, What You Need to Know

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Many people hope that getting a Covid-19 vaccine will mark an immediate return to normal: no more masks, no more distancing, safe indoor dinner parties and big hugs with friends. The reality is more complicated. For now, people who have gotten their shots must navigate decision-making in a world where the vaccinated and unvaccinated will coexist for months, even within the same household.

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Vincent Catala / Agence VU / Red​ux

If you're like most Americans, there's a good chance you're going to wear a cloth mask today. Doing so makes sense. It remains the official recommendation in the United States, and it is something we've both advocated since the beginning of the pandemic. Both of us wrote articles as far back as March urging people to wear homemade cloth masks. We're also the authors (along with 17 other experts) of a paper titled " An Evidence Review of Face Masks Against COVID," which was just published in peer-reviewed form in the Proceedings of the National Academy of Sciences. But it's past time for better solutions to be available to the public.

We first released the paper as a preprint back in April, and it took nine months to go through peer review. We're happy that it's published but, to be honest, we're also deeply disappointed that it's still relevant. We'd hoped that by 2021 supply chains would have ramped up enough to ensure that everyone had better masks. Cloth masks, especially homemade ones, were supposed to be a stopgap measure. Why are so many of us still wearing them?

Don't get us wrong; everything we said about the efficacy of cloth masks stands the test of time. Wearing them is much better than wearing nothing. They definitely help reduce transmission of the coronavirus from the wearer and likely protect the wearer to some degree as well. But we know that not all masks are equal, and early on in the pandemic, there was a dire shortage of higher-grade masks for medical workers. During those emergency conditions, something was much better than nothing. There are better possibilities now, but they require action and guidance by the authorities.

Recommended Reading

Even all cloth masks are not equal. Construction, materials, and fit matter, and these can't be tracked or certified with homemade masks. Unlike cloth masks, medical-grade masks (also called respirators) that adhere to standards such as N95 (in the U.S.), FFP2 (in the European Union), and KN95 (in China) do a much better job of protecting the wearer and dampening transmission. Ideally, they should also come with instructions on how to wear them and ensure that they fit properly.
Read: The real reason to wear a mask
Because we have written about masks, we've become informal advisers to friends, family, and strangers on the internet. We're not much help, though. When our friends ask us simple questions like "Where should I buy a mask?" or "Is my mask any good?," we don't have great answers. We can mumble generalities: Make sure it fits well; here are some guidelines about layers; try to avoid fake N95s. But if we can't give wholly satisfying answers to such basic questions, then how is the general public expected to fare?

Tragically, America is swamped with fraudulent medical-grade masks, some of which are only 1 percent effective. Many masks do not have labels clearly indicating their manufacturer. Some official mask-testing methods are inappropriate, including the use of far higher pressure than normal breathing exerts. No reasonable certification is available for the most useful masks generally available to the public. All of this means that everyone has to somehow figure out for themselves which masks are effective.

We routinely get PR pitches for excellent new solutions as well as snake-oil remedies, and we sometimes have trouble telling them apart-how is an ordinary person supposed to evaluate competing claims? When we share our articles about masks on social media, we are asked where to buy proper masks. Not only do we have no answer, but we often find that marketers will answer instead, directing readers to unreliable, overpriced masks. Worse, the supply situation apparently remains so dire that the CDC still "does not recommend that the general public wear N95 respirators," because they're crucial supplies that must continue to be reserved for health-care workers and other first responders.

Not all countries have this problem. Taiwan massively scaled up its manufacturing of masks at the start of 2020, such that by April every citizen received a fresh supply of high-quality masks each week, and the distribution system was regulated by the government. Taiwan's COVID-19 death rate per capita is more than 1,000 times lower than that in the U.S. Hong Kong has been distributing patented six-layer masks (the efficacy of which has been laboratory tested) to every citizen. Singapore is on at least its fourth round of distributing free, reusable, multilayer masks with filters to everyone-even kids, who get kid-size ones. In Germany, Bavaria has just announced that it will be requiring higher-grade masks. If all of these places can do this, why can't we?

Read: How a bizarre claim about masks has lived on for months

Fixing this problem is more urgent now that a new variant of the coronavirus, known as the B.1.1.7 lineage, is making its way around the world. This variant is believed to be about 50 to 70 percent more transmissible than earlier strains of the virus. Masks are an important part of the battle against this new variant because they decrease transmission by reducing the number of infectious particles spread by a mask wearer (known as "source control") and by reducing the amount that a mask wearer inhales. The cloth masks that we focus on in our paper do a good job at source control, but on their own they do not protect the wearer as well as medical-grade respirators do. That's why health-care workers wear respirators, and that's why leaving existing supplies for them was important early on-they were dealing directly with COVID-19 patients, so they needed the protection. Right now, while the CDC language on supply shortages has not been updated, it's unclear if that's because the shortages are really that dire or because this topic has not been paid sufficient attention. In either case, the CDC should update us on the situation. And if, indeed, we are still suffering from shortages, emergency measures should finally be implemented to manufacture such masks at home.

Not having higher-grade medical masks or even reliable, certified cloth masks distributed to the population means more transmission. But that's not all. If we could confidently tell people that the masks would also help protect the wearer from infection, we would likely get more people to wear them. Appealing to solidarity is excellent ("My mask protects you; your mask protects me"), but being able to confidently add self-interest to the equation would be even better.

Ideally we would have ramped up supply and been able to produce and distribute certified higher-filtration masks to the whole population. At a minimum, we should have created a certification program and a distribution channel that allows people to purchase higher-grade masks with confidence. Even better, we could have distributed them to the public for free like so many other places. It's not just that many other countries showed us the way: Many experts have been urging a switch to better-grade masks as soon as possible. For example, Abraar Karan and his co-authors wrote on the same topic many, many times, in May, June, October, and even this month. As Karan pointed out to us, the fact that some people refuse to wear masks makes it even more imperative that we distribute higher-grade masks to those willing to wear them.

We need the CDC and the FDA to step up and provide simple, clear, actionable, and specific information that would allow the public to know which masks are reliable and where they can get them, as well as how to upgrade and better wear their existing options. Initial studies suggest that widely available surgical masks, combined with a mask brace, could increase the effectiveness of the surgical masks. Cloth masks can be upgraded with a nose wire (for fit) and a filter insert-and more than 100,000 types of these masks are available on Etsy. A good supply of KN95 masks is available from China, with many supermarkets and pharmacies now selling them for a couple of dollars each. But none of these solutions can work widely as long as the public has little guidance on which masks are reliable and certified.

When, three months ago, one of us found FDA-certified KN95 masks at a local supermarket, she was shocked that they were just sitting in a large bin, next to similarly priced single-layer cloth masks. There was no run on them, because the public was not informed of their importance. When she spread word of the masks on social media, hoping some locals would be able to take advantage of this chance, she was inundated by people asking whether they were fake -a valid concern, given that the country is awash in fake masks. She ended up purchasing a bunch to distribute, an effort that would have been comical if it weren't so tragic.

One person reached out to say that his fiancée was about to undergo an organ transplant and was expected to do her rehabilitation wearing only cloth masks. A handoff of medical-grade masks was arranged. To an observer, it might have looked like a drug deal: people exiting their cars in a parking lot, searching for someone they clearly had not met before; both looking at the cars around them and their phone until they managed to meet up. Finally, a package was handed over, cash was offered but refused-an agreement was struck to pay it forward with a favor to someone else-and a relieved-looking man took the package back to his car and drove off. But it was much worse than a drug deal, the whole episode proof of a disastrous public-health breakdown in the United States.

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If you're like most Americans, there's a good chance you're going to wear a cloth mask today. Doing so makes sense. It remains the official recommendation in the United States, and it is something we've both advocated since the beginning of the pandemic.

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People make mRNA all the time. In our cells, DNA in the nucleus is used to make mRNA, which is sent to the cytoplasm where it serves as a blueprint to make proteins. Most of the time, the proteins that are produced are needed to help our bodies function.

mRNA vaccines take advantage of this process by introducing the mRNA for an important protein from the virus that the vaccine is trying to protect against. In the case of COVID-19, the important protein is the spike protein of the SARS-CoV-2 virus. The mRNA that codes for the SARS-CoV-2 spike protein is taken up by cells called dendritic cells, which express the spike protein on the cell surface, travel to a local lymph node, and stimulate other cells of the immune system (B cells) to make antibodies. These antibodies protect us, so that if we are exposed to SARS-CoV-2 in the future, our immune system is ready and we don't get sick. ( See more about dendritic cells and the adaptive immune system in this animation.)

Last updated 12/15/2020

Most people are able to get the COVID-19 vaccine, once supplies allow for their priority group to be vaccinated. But, a few groups of people should not get the vaccine, and some others should consult with their doctor or follow special procedures.
People who should NOT get the COVID-19 vaccine

Anyone with a severe allergy to a vaccine component (i.e., one that causes anaphylaxis or requires medical intervention)

Those younger than 16 years of age

People currently isolating or experiencing symptoms of COVID-19; these people can get vaccinated once they are finished isolation and their primary symptoms have resolved.

People who may get the vaccine after considering risks and benefits and/or consulting with their healthcare provider

Individuals with a history of severe allergy to any vaccine or injectable medication

Pregnant women

People with certain immune-compromising conditions

Breastfeeding women

People on anticoagulants

People who should follow special procedures

Someone with a history of severe allergy (requiring medical intervention) to anything other than a vaccine or injectable medication can get the vaccine, but they should remain at the vaccination location for medical observation for 30 minutes after receipt of the vaccine.

Pregnant women who develop a fever after vaccination should take acetaminophen. (See more in the pregnancy-related questions lower on this page.)

People who recently had COVID-19 and were treated with antibody-based therapies (e.g., monoclonal antibodies or convalescent plasma) should wait until 90 days after treatment to be vaccinated.

People with a known COVID-19 exposure should wait until their quarantine is over before getting vaccinated (unless they live in a group setting, such as a nursing home, correctional facility, or homeless shelter, in which case they can be vaccinated during the quarantine period).

People who got another vaccine (non-COVID-19 vaccine) should wait at least 14 days before getting COVID-19 vaccine. Likewise, if a person got the COVID-19 vaccine, they should wait at least 14 days before getting any other vaccines (non-COVID-19 vaccines).

Last updated 12/29/2020

Side effects from both mRNA vaccines are caused as part of the immune response to the vaccines. In some ways, the more vigorous the immune response, the more common the side effects.

The most common side effects from the mRNA vaccines are:

Side effects occurred during the first week after vaccination, but were most likely one or two days after receipt of the vaccine. Side effects were more frequent following the second dose and more likely to be experienced by younger, rather than older, recipients. Although most people will not have significant side effects, some people may wish to schedule their vaccination, so that they will not need to call out of work the next day if they don't feel well.

Last updated 12/15/2020

The mRNA vaccines are not composed of live viruses, so there is no infectious virus to spread from a vaccinated person to someone else. But, we do not yet know if a vaccinated person who encounters the virus can still experience what is referred to as "asymptomatic infection." An asymptomatic infection occurs when a person is exposed to the virus in the community and the virus can still replicate in their body, but they don't have symptoms because their immune system stifles the infection as a result of vaccination. In this scenario, the person could potentially spread the virus without even knowing they are infected.

Given that families may not all get vaccinated at the same time, those who have been vaccinated should continue to practice public health measures when they are out in the community to decrease the chance of introducing the virus in the home through asymptomatic infection. Likewise, even when a whole family is vaccinated, continuing to practice these measures will be important for two reasons:

1. The vaccine will not work for everyone, so someone in the home who has been vaccinated may still be susceptible.

2. People outside of the family's "bubble," like co-workers, extended family members, neighbors, and others they come into contact with, may not have been vaccinated (or may be in the group for whom the vaccine does not work).

This approach will be important until we can get control over the spread of virus. Once enough people have been vaccinated to slow the spread of the virus, we will all be able to move away from these public health measures. But, for now, we need to continue working together to decrease spread of the virus by masking, physical distancing, handwashing, and getting vaccinated.

Last updated: 12/22/2020
The mRNA vaccines include:

mRNA - This mRNA is for the spike protein of SARS-CoV-2, the virus that causes COVID-19.

Lipids - These are molecules that are not able to dissolve in water. They protect the mRNA, so that it does not break down before it gets into our cells. These can be thought of as little "bubbles of fat," which surround the mRNA like a protective wall. There are four different lipids in the Pfizer vaccine and three in the Moderna vaccine. One of the lipids in both vaccines is cholesterol. The lipids are the most likely components of the vaccine to cause allergic reactions.

Salts and amines - The Pfizer vaccine contains four salts. One is table salt. The salts are used to keep the pH of the vaccine similar to that found in the body, so that the vaccine does not damage cells when it is administered. The Moderna vaccine also contains four chemicals to balance the pH, but two are in a class of organic compounds known as "amines" and two are acetic acid and its salt form, sodium acetate. Acetic acid is the main component of vinegar (other than water).

Sugar - This ingredient is literally the same as that which you put in your coffee or on your cereal. It is used in both of the vaccines to help keep the "bubbles of fat" from sticking to each other or to the sides of the vaccine vial.

These are the only ingredients in the mRNA vaccines.
The mRNA vaccines do not include any of the following:
Last updated 12/22/2020

No. Because the mRNA vaccines do not involve growing SARS-CoV-2 virus in cells to produce the vaccine, they do not contain antibiotics.

Last updated: 12/22/2020

A few different concepts are at work here, so let's look at each individually:

Regarding changing efficacy - The Moderna vaccine was originally reported to have 100% efficacy against severe disease. This report was a result of the fact that no people in the vaccine group had a severe case of COVID-19 when they pulled together their data to submit it to the FDA. Thereafter, one person in the vaccine group developed symptoms that could qualify as a "severe case of COVID-19," according to their study definition. This person's diagnosis meant the calculations changed, hence a lower efficacy. If we consider that vaccines are typically not 100% effective, we would expect that over time some people in the vaccine group would likely develop disease, but likewise, over time, more people in the placebo group would as well. So scientifically speaking, this change is not concerning.

Regarding lower efficacy in older adults -Moderna found 94.1% efficacy in all age groups, but only 86.5% in those over 65 years of age. The efficacy in older adults was calculated based on a very small number of vaccine recipients over 65 years of age getting the disease (4 of them) compared with the number over 65 in the placebo group who got sick (29). It is expected that, as with the Pfizer vaccine, people over 65 are well protected and that this perceived difference is reflective of the small numbers of older adults who experienced disease through that point in the trial. As the company continues monitoring trial participants, we will learn more.

With all of this said, it is important to be aware that as these vaccines start to be used in the general population, we will find lower levels of protection "in the real world." You can think of this as being analogous to "gas efficiency" rates that we look at when we buy a car. What you see on the window sticker at the time of purchase is not necessarily what you experience when you buy the car because the actual number relies on how you and other consumers use your cars (e.g., highway versus local driving), whereas the manufacturer measures gas efficiency under strict conditions. In the case of vaccines, clinical trials represent well-controlled settings compared with general use in the population. This phenomenon is so well-known that scientists refer to "efficacy" and "effectiveness" when talking about how well a vaccine works.

Efficacy is what we know from a clinical trial

Effectiveness is what is experienced when the vaccine is used with the general public.

However, even if efficacy was 95% and effectiveness falls to 80%, that still means 8 of every 10 people who get vaccinated are spared from the disease.

You can read a comparison of the Moderna and Pfizer vaccines in this article.

Last updated: 12/22/2020

Since mRNA is active only in a cell's cytoplasm and DNA is located in the nucleus, mRNA vaccines do not operate in the same cellular compartment that DNA is located.

Further, mRNA is quite unstable and remains in the cell cytoplasm for only a limited time (See "What stops the body from continuing to produce the COVID-19 spike protein after getting an mRNA vaccine?" below.) mRNA never enters the nucleus where the DNA is located so it can't alter DNA.
Watch this short video of Dr. Offit describing how mRNA vaccines work.
Last updated 12/15/2020

Because our cells are continuously producing proteins, they need a way to ensure that too many proteins do not accumulate in the cell. So, generally speaking, mRNA is always broken down fairly quickly. Even if for some reason our cells did not breakdown the vaccine mRNA, the mRNA stops making the protein within 10-14 days, regardless of the body's immune response to the protein.

Last updated 12/15/2020

More than 9 of every 10 people vaccinated during the clinical trials were protected from disease. This number may decrease a bit as the vaccines are given to the general population because the conditions during a clinical trial tend to be optimal, so they measure the best case scenario. However, it is still expected that most people who get both doses of the vaccine, according to the time interval recommended, will be protected.

Last updated 12/15/2020

The CDC does not recommend testing prior to vaccination because it would be very difficult to coordinate and there is no reason to suspect that there would be an issue. For example, we give vaccines for measles, chickenpox, and rabies after a person has been exposed (meaning when they are already infected), and there are not issues. Likewise, the Pfizer clinical trials included people who did or did not have COVID-19 previously and some people got the virus during the study. These situations did not present any issues of concern either.

Last updated 12/21/2020

Everyone will still need to practice recommended public health measures for a while because it will take some time to slow or stop the spread of the virus. Two factors are important for understanding why:

While the vaccines appear to be highly effective at preventing disease, it might not prevent asymptomatic infection, meaning vaccine recipients might still be able to get infected, but not have symptoms and, therefore, unwittingly spread the virus. The companies will be doing additional studies to better understand whether this is the case.

Scientists estimate that to control COVID-19, about 7 or 8 of every 10 people will need to be immune. Given that the U.S. population is more than 330 million people, this means that almost 250 million of them will need to be immune to reach this goal. Between March and November 2020, almost 12 million people in the U.S. were found to be infected, although estimates from antibody studies suggest that the number might be 3-7 times greater. Despite this the virus rages on, demonstrating just how many more people need to become immune before we can expect to control the spread of COVID-19. This also shows how important vaccines are in controlling the spread because more than 250,000 people died as a result of COVID-19 infections between March and November 2020. If we had to rely on infections alone to stop the spread of COVID-19, between 1 million and 5.4 million people would die on the way to 250 million people becoming immune.

For these reasons, there will still be some period of time during which other measures, such as masks, social distancing, and other public health measures, will be required to slow or stop the spread of the virus. And, because we won't know who might still be able to be infected after vaccination or previous illness, everyone will be asked to comply. Watch Dr. Offit discuss the continued need for masks and social distancing in this short video.

Last updated 12/15/2020

Several approaches to COVID-19 vaccines are currently being tested. They include both tried-and-true as well as novel approaches.

Here is a brief summary of these different strategies:

Inactivated vaccine - The whole virus is killed with a chemical and used to make the vaccine. This is the same approach that is used to make the inactivated polio (shot), hepatitis A and rabies vaccines.

Subunit vaccine - A piece of the virus that is important for immunity, like the spike protein of COVID-19, is used to make the vaccine. This is the same approach that is used to make the hepatitis and human papillomavirus vaccines.

Weakened, live viral vaccine - The virus is grown in the lab in cells different from those it infects in people. As the virus gets better at growing in the lab, it becomes less capable of reproducing in people. The weakened virus is then used to make the vaccine. When the weakened virus is given to people, it can reproduce enough to generate an immune response, but not enough to make the person sick. This is the same approach that is used to make the measles, mumps, rubella, chickenpox and one of the rotavirus vaccines.

Replicating viral vector vaccine - In this case, scientists take a virus that doesn't cause disease in people (called a vector virus) and add a gene that codes for, in this case, the coronavirus spike protein. Genes are blueprints that tell cells how to make proteins. The spike protein of COVID-19 is important because it attaches the virus to cells. When the vaccine is given, the vector virus reproduces in cells and the immune system makes antibodies against its proteins, which now includes the COVID-19 spike protein. As a result, the antibodies directed against the spike protein will prevent COVID-19 from binding to cells, and, therefore, prevent infection. This is the same approach that was used to make the Ebola virus vaccine. (To see how viruses reproduce in cells, watch this short animation.)

Non-replicating viral vector vaccine - Similar to replicating viral vector vaccines, a gene is inserted into a vector virus, but the vector virus does not reproduce in the vaccine recipient. Although the virus can't make all of the proteins it needs to reproduce itself, it can make some proteins, including the COVID-19 spike protein. No currently licensed vaccines use this approach.

DNA vaccine - The gene that codes for the COVID-19 spike protein is inserted into a small, circular piece of DNA, called a plasmid. The plasmids are then injected as the vaccine. No currently licensed vaccines use this approach.

mRNA vaccine - In this approach, the vaccine contains messenger RNA, called mRNA. mRNA is processed in cells to make proteins. Once the proteins are produced, the immune system will make a response against them to create immunity. In this case, the protein produced is the COVID-19 spike protein. The Pfizer and Moderna COVID-19 vaccines use this approach. Watch this short video in which Dr. Offit discusses how mRNA vaccines work.

Hear more about the types of vaccines being tested in this recorded event presented by Dr. Offit, Director of the Vaccine Education Center - Current Issues in Vaccines, December 9, 2020. This webinar series is supported by the Thomas F. McNair Scott Endowed Research and Lectureship Fund and co-sponsored by the PA Chapter, American Academy of Pediatrics and Wilkes University. (For healthcare providers wishing to obtain continuing education credits for viewing this recorded event, please review the continuing education information on this page.) View answers to a series of questions asked during the event.

You can also visit the Vaccine Makers Project page, "The Coronavirus Pandemic - Answering Your Questions" for more details about the types of vaccines being studied. (See the "April 6" entry), or watch this CNBC interview with Dr. Offit for animations showing how some of these approaches work.

Last updated 12/15/2020

It is likely that more than one of these approaches will work, but until large clinical trials are completed, we won't know for sure. Likewise, the different approaches may have different strengths and weaknesses. For example, mRNA or DNA vaccines are much faster to produce, but neither has previously been used to successfully make a vaccine that has been used in people. On the other hand, killed viral vaccines and live, weakened viral vaccines have been used in people safely and effectively for many years, but they take longer to produce.

In addition to differences in how long it takes to make different types of vaccines, each type may also cause the immune system to respond differently. Understanding the immune responses that are generated will be important for determining whether additional (booster) doses will be needed, how long vaccine recipients will be protected, and if one type offers benefits over another.

Last updated 12/15/2020

Each vaccine will need to be tested in various age groups; however, both the Pfizer and Moderna mRNA vaccines worked well in older adults.

Some of the traditional approach vaccines may not be effective in elderly populations. But if that is found to be the case, alternative versions may be explored, such as higher dose versions, as was done for influenza vaccines. Another possibility would be to deliver the SARS-CoV-2 spike protein with one or two powerful adjuvants, similar to what was done with the shingles vaccine, known as Shingrix ®, which works well in the elderly.

Last updated 12/15/2020

None of the early vaccines (those by Moderna, Pfizer, AstraZeneca, or Johnson & Johnson) are live weakened versions (similar, for example, to the measles, mumps, rubella, or varicella (chickenpox) vaccines). Moderna's and Pfizer's are mRNA vaccines, and AstraZeneca's and Johnson & Johnson's are non-replicating vectored vaccines. You can learn more about the different types of vaccines being tested in the response to "What types of COVID-19 vaccines are being tested?"

Last updated 12/15/2020

The mRNA vaccines (those by Pfizer and Moderna) do not contain fetal cells.

But, a few of the other vaccines being studied use cells originally isolated from fetal tissue (often referred to as fetal cells). These fetal cells are used to grow the vaccine virus. Some of these potential vaccines are currently being tested in people.

The fetal cells being used to produce some of the potential COVID-19 vaccines are derived from two sources (HEK-293 and PER.C6), neither of which is used to produce any existing vaccines grown in fetal cells:

HEK-293 - This is a kidney cell line that was isolated from a terminated fetus in 1972.

PER.C6 - This is a retinal cell line that was isolated from a terminated fetus in 1985.

These cell lines are used to make two of the non-replicating viral vector vaccines being evaluated.

Check this article in Science for a table showing some of the candidate vaccines that use these cell lines and to learn more about a letter to the Food and Drug Administration (FDA) discouraging use of these cell lines for COVID-19 vaccine production.

Last updated 12/15/2020

The mRNA vaccines require two doses. For the Pfizer vaccine, doses should be separated by 21 days. For Moderna's vaccine, doses should be separated by 28 days. The two mRNA vaccines are not interchangeable. A person should be sure they know which one they got as the first dose and be clear about when they should return for the second dose, particularly because the vaccines require both doses to have the best protection.

Some COVID-19 vaccines being evaluated only require a single dose, but the clinical trials will provide more information about how many doses of each vaccine will be needed.

Last updated 12/15/2020

Since the first people in the trials were vaccinated at the end of July 2020 and the first vaccines were approved in December 2020, we only have information about protection against disease for a few months after vaccination. The degree to which these vaccines protect against COVID-19 one or two years after vaccination will be determined later. Trial participants will continue to be monitored, so we will learn more, but we do not yet know whether booster doses will be needed.

Last updated 12/15/2020

We do not yet know how long immunity lasts after infection or vaccination:

Infection - Scientists are working to learn more about immunity following infection. While some people have been re-infected after recovering from COVID-19, the number of people who have experienced this is small compared with the total number of people who have been infected. Likewise, although the virus has been changing since it was first recognized, antibodies from people who were sick early during the pandemic are still effective against the slightly modified version. For these reasons, scientists are hopeful that people will be protected for one or more years.

Vaccination - Clinical trial participants will be monitored to understand how long immunity lasts after vaccination.

Last updated 12/15/2020

People who had COVID-19 are recommended to get the vaccine after they have recovered. The vaccine trials included people who were previously infected with SARS-CoV-2, and the vaccine was found to be safe. Because we do not know how long antibodies last after infection and a small number of people have had more severe second bouts of infection, the vaccine can be beneficial in boosting a person's existing immunity from infection.
Watch this short video in which Dr. Offit discusses what is known about COVID-19 reinfection.
Last updated 12/15/2020

People who currently have COVID-19 should wait until they have recovered and meet the criteria to stop isolating.

If a person had antibody therapy as part of their treatment, they should wait for 3 months before getting the vaccine.

Last updated 12/15/2020

People will not spread the virus after vaccination with the mRNA vaccines since they are not live vaccines that reproduce the whole virus in the body.

But, we do not yet know if the COVID-19 mRNA vaccines prevent infection or if they only prevent disease:

Disease means people experience symptoms of illness.

Infection means that a virus can infect a person's cells and reproduce, but the person may or may not have symptoms or be contagious.

If the COVID-19 mRNA vaccines only prevent disease, a person could be infected following an exposure and potentially spread the virus. Additional studies will be completed to determine whether the vaccines prevent infection as well as disease. However, given this uncertainty, vaccinated people will still need to use masks and practice social distancing measures for some time.

Last updated 12/15/2020

At least at first, COVID-19 vaccines are not be interchangeable.

Three scenarios can occur if a person gets vaccinated with two versions of vaccines against the same disease, particularly close in time:

They get a stronger immune response. An example of this was when children got inactivated polio vaccine and later got oral polio vaccine.

The second vaccine causes immunity that would be similar to receiving a second dose of the original vaccine. Using a different brand of hepatitis B vaccine for one or more doses would be an example of this.

The immune response generated by the first vaccine interferes with components of the response to the second vaccine, in some cases causing lower immunity. For example, when people got a pneumococcal polysaccharide vaccine (PPSV) followed by a pneumococcal polysaccharide vaccine with a harmless helper protein attached to it, called pneumococcal conjugate vaccine (PCV), they had lower antibody responses to one part of the PCV vaccine than people who got the two vaccines in the opposite order (PCV followed by PPSV).

For these reasons, studies will need to be done to determine the effects of getting a second type of COVID-19 vaccine shortly after receiving a different one. If, however, we find that COVID-19 vaccines are like influenza vaccines and we need to get vaccinated annually, concerns about switching types from one year to the next are less likely to be an issue.

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SARS-CoV-2 infections can be a minor hindrance or lead to severe disease or even death. While hygiene measures such as social distancing, handwashing, and wearing masks offer some help, the best way to stop this virus is to generate SARS-CoV-2-specific immunity. No virus has ever eliminated itself by inducing natural immunity in a large percentage of the population. Only herd immunity induced by vaccination can eliminate viruses, as has now been shown for smallpox and two of the three different types of poliovirus.

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The mRNA vaccines require two doses. While people will have some immunity after the first dose, protection will be most likely about one week after receipt of the second dose.

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Viral mutations can cause vaccines to be less effective, such as we see with the influenza virus, so it is reasonable to wonder whether changes to SARS-CoV-2 will affect COVID-19 vaccines. Although SARS-CoV-2 is constantly mutating, the critical question is does the virus's mutation change function, making the virus more or less virulent or more or less contagious. So far, the virus that causes COVID-19 does not appear to functionally change in an important way. But, it does happen and at some point a change could affect how well a vaccine works. Right now, that does not appear to be happening. For example, previous changes enabled the virus to spread more easily, but that change did not affect the way antibodies respond to the virus. Antibodies from people who had an earlier version of the virus are still able to protect against the newer version, so vaccine would also still be effective. In other words, at least to date, the virus hasn't mutated away from the approach taken to combat COVID-19 with vaccines.

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Vaccine manufacturers have to follow guidance provided by the Food and Drug Administration (FDA) while developing any coronavirus vaccine. This includes requirements to share information about how they determined that a vaccine is safe and that it works. Each company with a potential vaccine will need to provide data for review and information, so the FDA and other scientists can understand things like:

How the studies were designed

How many people were evaluated

How the testing to obtain the data was done

The FDA has also encouraged manufacturers to include people who represent the populations most affected by coronavirus in their studies, such as racial and ethnic minorities as well as older people and those with underlying illnesses.

Despite the shortened vaccine development timeline, the FDA has issued assurances that they will not approve a vaccine that was developed by sacrificing the standards for quality, safety, and efficacy that any other vaccine would need to meet. A group of vaccine manufacturers have also signed a pledge not to submit a COVID-19 vaccine before phase III studies have demonstrated that their candidate vaccine is safe and effective. The Biotechnology Innovation Organization (BIO) has also released an open letter to companies making COVID-19 vaccines regarding the standards that should be followed.

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The studies may be designed to measure slightly different things depending on the different companies:

Viral shedding - When people are infected with COVID-19, virus particles can be found in the secretions from their nose and mouth. Some studies are measuring whether vaccinated people have virus in these secretions, called viral shedding. With this approach, even if a person does not have symptoms, scientists can tell if the person was infected.

Protection against moderate or severe disease - In these studies, scientists evaluate people for specific symptoms of infection that are considered to represent more severe disease. By comparing the rates of these symptoms in people who were or were not vaccinated, they can tell if the vaccine protected more people from getting more severely ill. This is how the Pfizer and Moderna studies were done.

Some studies are evaluating both viral shedding and protection against moderate or severe disease.

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Pregnant women were not included in the early COVID-19 vaccine studies, but some participants were either pregnant and did not know it or became pregnant during the course of the study. As a result, we only have a small amount of data regarding the safety of these vaccines in pregnant women. The good news is that in this small group of women, no concerns were found and the vaccine worked, but it will be important to get data on larger numbers of women moving forward.

Despite the limited amount of data, both the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) have recommended that pregnant women who are part of a group recommended to get the COVID-19 vaccine may be vaccinated if they choose to do so. These women should be supported in their decision-making efforts by their doctors and be provided with information related to the potential risks and benefits, but they do not have to wait to have a consultation with their healthcare provider before being vaccinated if they are comfortable doing so.

Two factors, in addition to the limited vaccine data, were important for informing these recommendations. First, some pregnant women will be at high risk for COVID-19, such as healthcare workers or those with certain health conditions. Second, pregnant women are at increased risk of developing complications, compared with their non-pregnant peers, when infected with COVID-19.
All pregnant women should keep these two important points in mind:

1. Pregnant women who decide to get the COVID-19 vaccine should take acetaminophen if they develop a fever after vaccination, as fever during pregnancy can negatively affect a developing baby. Taking acetaminophen during pregnancy has been found to be safe.

2. Likewise, regardless of whether or not a pregnant woman decides to be vaccinated, she should practice recommended public health measures, particularly because of the increased risk to pregnant women infected with COVID-19.

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Yes. Although women who are breastfeeding were not included in the clinical trials, current data suggest that COVID-19 is not transmitted through breast milk, so it is not expected that vaccination would cause a concern either. On the other hand, some women who are breastfeeding will be at higher risk for exposure, so they could benefit from receiving the vaccine.

In addition, women do not need to delay breastfeeding for any period of time after they have been vaccinated.

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Yes, women who are trying to get pregnant can get the vaccine. Likewise, if a woman finds out she is pregnant after getting the first dose, but before getting the second dose, she can still get the second dose on time.

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No, you do not need to delay pregnancy. But, if you become pregnant within 30 days of receiving a dose of vaccine, you should consider registering for V-SAFE, a mobile-app based program being offered by the CDC that is tracking the safety of COVID-19 vaccines.

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Yes. Studies of COVID-19 vaccines in children have started. The Pfizer mRNA vaccine was tested in some 16- to 18-year olds and has been approved for teens in this age group. As more information becomes available in younger children and teens, the age-related recommendations will be adjusted.

It is important that COVID-19 vaccines be thoroughly tested in children younger than 18 years of age before they are given in this group because we cannot assume that they will act the same way in children. This will be particularly important since we have seen that children are not affected in the same way by COVID-19 infections.
Watch this short video in which Dr. Offit discusses testing COVID-19 vaccines and children.
People with immune-compromising conditions may get the COVID-19 vaccine as long as they are not in one of the following categories:

Severe allergy to a vaccine component (i.e., one that causes anaphylaxis or requires medical intervention)

History of severe allergy to any vaccine or injectable medication

However, it is recommended that individuals with compromised immune systems discuss their personal risks and benefits with a healthcare provider to determine whether to receive the vaccine. Data about how well the vaccine works and its safety in immune-compromised individuals are not currently available, so it is possible that these individuals could have a lower immune response to vaccination. On the other hand, persons with these conditions may also be at higher risk of severe disease due to COVID-19. Therefore, the CDC recommended that people who are immune-compromised or taking immunosuppressive medications could receive the vaccine if they wanted as long as they do not have other contraindications.

With this said, knowing the potential for a lower immune response, if someone with an immune-compromising condition decides to get vaccinated, it will be important to get both doses and practice other public health measures until more is known about their protection against SARS-CoV-2, the virus that causes COVID-19.Post-licensure monitoring systems, like the Vaccine Adverse Events Reporting System (VAERS) and the Vaccine Safety Datalink (VSD), will be used to allow for real-time monitoring of these sub-groups.

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It would not be expected that the mRNA vaccines would cross the blood-brain barrier for two main reasons:

Most of the protein that is made is bound to cells - The vaccine is injected into muscle, where dendritic cells in the area use the mRNA to make the COVID-19 spike protein. These dendritic cells, after making the spike protein, put the protein (not the mRNA) on the cell surface, travel to the nearest lymph node, and stimulate other cells of the immune system to make an immune response against the protein. This process is typical of our adaptive immune system, which you can find out more about in this animation.

The protein itself is too large to cross the BBB.

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Antibody-dependent enhancement (ADE) has not been identified as a concern related to SARS-CoV-2 infection or following COVID-19 vaccination. In fact, a body of evidence has suggested that ADE will not be a concern:

First, most people have been infected with other coronaviruses in their lifetime, and ADE has not been identified as a result of these infections.

Second, in human studies, people previously infected with coronavirus were infected with different types of coronavirus, and they did not experience enhanced disease.

Third, experimental animals vaccinated against SARS-CoV-2 did not develop enhanced disease when challenged, or infected, with the virus.

Finally, when people with COVID-19 received plasma containing SARS-CoV-2 antibodies, they did not experience enhanced disease.

For these reasons, ADE is not expected to be a concern for SARS-CoV-2 infections or vaccination.

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Infertility has not been found to be an issue in women infected with COVID-19, so it would not be expected to be a concern for the vaccine.

Concerns about antibodies generated by the COVID-19 vaccine attacking syncytin-1, a protein associated with the placenta during pregnancy, are unfounded. The claims, which circulated online, were based on a small number of similar amino acids in the two proteins, but the overlap is not sufficient to cause such a reaction. This notion has been addressed by Full Fact.

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The U.S. Centers for Disease Control and Prevention (CDC) created a framework, informed by the efforts of other groups, to advise states regarding the equitable distribution of limited supplies of COVID-19 vaccines:

With this information states, territories, and local health departments each created their own prioritization plans and submitted them to the CDC. You can see the executive summaries of each plan on this page of the CDC's website. However, these plans are continually being updated and adapted as more information becomes available. Therefore, you may wish to visit the website of your state, territory, or local department of health to find out more about what is happening in your area.

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Both Pfizer and Moderna have provided estimated doses, but the number of doses for the U.S. and how many doses will be allotted to various states and territories remains to be determined. Here is what is currently known:

Pfizer - 50 million doses by end of 2020 and 1.3 billion doses by end of 2021. These are global supply estimates, and the vaccine requires two doses, so about 25 million people could be immunized with the supply from late 2020 and 650 million by late 2021.

Moderna - 20 million dose for the U.S. by end of 2020 and 500 million to 1 billion doses by end of 2021. These are U.S.-based doses, and the vaccine requires two doses, so about 10 million people could be immunized with the late 2020 supply and 250 to 500 million people in 2021.

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In most states and areas throughout the U.S., it is expected that frontline healthcare providers and residents of long-term care facilities will be prioritized, followed by sectors of the population at higher risk of suffering severe disease and death, such as essential workers and those with health conditions that put them at higher risk.

State and local health departments are basing their plans on recommendations made by the Centers for Disease Control and Prevention (CDC):

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While we cannot know for sure, if both the Pfizer and Moderna vaccines are provided in the quantities they estimate producing, it is expected that by summer or fall of 2021 most people who want a COVID-19 vaccine should be able to receive it, as long as they do not have a contraindication that prevents them from receiving these versions.

Likewise, it is possible that vaccines produced by Johnson & Johnson and AstraZeneca will become available during 2021 that could change these projections.

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People should separate their COVID-19 vaccinations by at least 14 days from any other vaccine (before or after). This recommendation is based on the fact that we currently do not have data regarding whether the COVID-19 vaccines will affect, or be affected by, other vaccines. Studies to determine whether COVID-19 vaccines can be given with the flu vaccine or the shingles vaccine will be completed; these types of studies are called "concomitant use studies."

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The vaccine will be thawed, allowed to come to room temperature, and diluted with a salt solution before being administered. Providers will be given specific instructions to ensure that how they handle the vaccine will not affect its effectiveness.

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Talk with your healthcare provider about when you personally can get your influenza vaccine, but generally speaking, people can get a flu vaccine once they no longer have symptoms of COVID-19.

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The lingering effects of COVID-19 are concerning, and we still have much to learn about them. A vaccine will help from the point of view that if it decreases infections, fewer people will experience illness and, therefore, fewer people will experience long-term effects. But, it is not likely that a vaccine will address these effects in someone who was already infected.

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No. Influenza viruses and coronaviruses are different, so the flu vaccine does not protect against coronavirus. You can learn more about the differences between these two viruses:

Even though flu vaccine does not protect against COVID-19, it is more important than ever to get an influenza vaccine this year:

For individuals - Preventing influenza infection will help people in two ways. First, since several of the symptoms of influenza and COVID-19 are similar, it will help with determining the cause of an infection this winter. Second, many people who die after having influenza actually die from a second infection. These second infections are called "opportunistic infections." They are often the result of bacterial infections that capitalize on lung damage caused by influenza, leading to pneumonia. Given that COVID-19 also affects the lungs, it is possible that influenza infection could be complicated by COVID-19. It will take time to figure out the effects of these two infections on the lungs if they occur at or near the same time, so preventing or lowering the chance of influenza infection is important.

For healthcare systems - Every year, hundreds of thousands of people are hospitalized with influenza. Given that COVID-19 is already straining medical resources, it is possible that the impact of influenza and COVID-19 occurring at the same time will overwhelm healthcare systems, leading to both difficult decisions about how to best provide care and unnecessary deaths.

For communities - If both COVID-19 and influenza are spreading in communities and people are uncertain which they have, it could lead to excessive quarantines and shutdowns that contribute to an already fragile economic recovery. Likewise, from a public health standpoint, more people immunized against influenza will decrease its spread. So, overall, communities will be healthier, and community resources, such as EMTs, ambulances, public health, and related services will not be further overwhelmed by influenza.

Find out more and see tips for keeping your family healthy in the September 2020 Parents PACK article, "Coronavirus, influenza ... Feel more in control this fall."
Watch this short video in which Dr. Offit describes the importance of getting flu vaccine during the COVID-19 pandemic.
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Vaccines against pneumonia, such as the pneumococcal, Haemophilus influenzae type b (Hib), and meningococcal vaccines, are not likely to protect against COVID-19 disease.

However, the pneumococcal, Hib, and meningococcal vaccines prevent other serious infections. For more information about these vaccines and the diseases they prevent, go to:

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The anthrax vaccine has not been tested for any ability to provide protection against COVID-19 disease, nor would it be expected to do so.

The anthrax vaccine is not routinely recommended in the U.S., but some high risk groups of people are recommended to get it. Find out more on the "A Look at Each Vaccine: Anthrax Vaccine" webpage.

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Coronavirus vaccines will be distributed for free; however, insurance companies may have to cover the cost of administering the vaccine.

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Given that COVID-19 vaccines were made more quickly than other vaccines, it is understandable to be concerned about their safety, but the following can provide reassurances:

Phase III trials for COVID-19 vaccines have been as large as those for other vaccines, including tens of thousands of participants. While these trials may not uncover rare adverse events (that occur in the millions), we can be comfortable that these trials were large enough to detect any major safety concerns.

For each new vaccine, the data from these large phase III vaccine trials will undergo several rounds of review by different, independent groups of experts in immunology, statistics, infectious diseases, virology, and vaccinology:

The trials are coded, so that the manufacturers do not know who got vaccine and who got placebo. During this time, an independent group of experts monitor the data to make sure that no concerning developments occur with trial participants.

Once the company submits the data to the Food and Drug Administration (FDA), an advisory committee of independent experts, called the Vaccine and Related Biologics Product Approval Committee (VRBPAC) reviews the data to evaluate vaccine safety and effectiveness. This committee provides advice to the FDA before a vaccine can be accepted.

Once a vaccine is approved by the FDA, the data undergo a third round of review, by yet another committee of experts. This group, called the Advisory Committee on Immunization Practices (ACIP), reviews the data and make recommendations to the Centers for Disease Control and Prevention (CDC) regarding who should or should not get the vaccine and when, based on the data.

As a result, by the time a vaccine can be given to any individual, the results of the phase III trials have been reviewed and discussed regarding their scientific merit by more than 50 independent experts, in addition to the scientists at the companies and their own trial advisory groups.
Watch this short video to hear Dr. Offit discuss how we will know a COVID-19 vaccine is safe.
COVID-19 vaccines will be approved using the FDA's "Emergency Use Authorization (EUA)" process, rather than the typical "Biologics Licensing Application (BLA)" process, due to the emergency we face resulting from the pandemic. However, the main difference between these processes from the point of view of vaccines is that under the EUA process, the vaccines will be approved more quickly, so they can get to people faster. As such, companies will need to continue monitoring the trial participants and submit subsequent findings to the FDA. In reality, companies usually continue following participants, but the time difference here is that rather than having studied the vaccine for several years, it has only been studied for several months; therefore, the additional monitoring will be critical to continuing to understand the durability of immune responses to the vaccine.

To find out more about the emergency use authorization compared to the typical vaccine approval process, watch this interview with Dr. Offit posted by Medscape (October 27, 2020).

Finally, once a vaccine is approved and individuals are deciding whether to get it, they will also have access to information that summarizes the clinical trial findings, particularly related to any side effects found during the trials and who should or should not get the vaccine. In the U.S., a document called a Vaccine Information Statement, or VIS, is legally required to be presented before every dose of vaccine is given. While a COVID-19 vaccine will be approved outside of the normal process, because of the EUA protocol, a VIS, or similar document, should still be made available to provide the information that individuals will need to make informed decisions based on the known risks and benefits.

To read more about the history of the VIS, see "History of Vaccine Information Statements," produced by the Centers for Disease Control and Prevention.

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The mRNA vaccines do not contain any blood products. We will not know about the ingredients of other vaccines until each is submitted for approval, as companies are required to share this type of information.

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DNA vaccines are among the types being tested to prevent COVID-19. DNA vaccines may offer an advantage to other types of vaccines because they do not need to use the virus to produce an immune response. Other DNA vaccines in development (including for influenza, HPV, and HIV) have been extensively tested in animals and people and shown to be safe.

Some people are concerned that DNA vaccines could change people's existing DNA. While it is the case that the DNA from the vaccine is treated the same as human DNA in the cell, two points are worth considering. First, DNA vaccines have not historically worked as well as other types because it is difficult to get enough DNA introduced to the vaccine recipient to make a strong immune response. Second, even when it is introduced successfully, vaccine DNA only enters a few cells, which then produce viral proteins that, once released from the cell, activate the immune system to generate immunity.

As such, concerns related to a person's DNA being altered by DNA vaccines are theoretical concerns without evidence. Since all vaccines are required to go through extensive testing before approval, the same standard will be applied to DNA vaccines as will be applied to any other COVID-19 vaccine. Only then will we know whether DNA vaccines will be useful in protecting against COVID-19.

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The November 2020 issue of Parents PACK offered tips for families as they plan for the holidays. Topics addressed include advance planning, travel and lodging, and during- and after-event precautions.

Check out the article on this page or download a PDF for sharing.

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Stay-at-home orders have been used as a way to decrease the spread of COVID-19; however, it is unlikely that the country will experience widespread shutdowns like those implemented in the spring of 2020. Rather, it is expected that locally targeted public health measures will be "turned up" and "turned down," depending on situations in each community.

With this said, the virus is currently spreading so rapidly that we may see many communities or larger geographic areas concurrently implementing measures to slow the spread, particularly as the holidays may increase an already "out-of-control" spread. Indeed, the CDC recently asked Americans not to travel during the Thanksgiving and Christmas holidays. The best way to decrease the need for restrictions is for communities to ban together when it comes to wearing masks and social distancing, particularly until enough people have been immunized to make it difficult for the virus to find susceptible people in the community.

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Several tools have been developed to help public health officials, governments, businesses, and individuals make informed decisions. These tools use county-level data to provide guidance. Two that may be particularly helpful include:

COVID-Lab: Mapping COVID-19 in your community - Developed by PolicyLab at Children's Hospital of Philadelphia, this tool allows you to see COVID-19 test positivity in counties throughout the United States. The tool also offers projections for how levels of disease are expected to change in the next four weeks based on current social distancing practices, population density, testing capacity, and anticipated temperature and humidity.

COVID-19 event risk assessment planning tool - Developed by teams at Georgia Institute of Technology and Applied Bioinformatics Laboratory, this tool offers information about gatherings by county throughout the U.S., showing the percent chance that at least one person will be COVID-19 positive in gatherings of different sizes. The calculations are based on results of data from COVID-19 antibody blood tests.

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Herd immunity is a concept used in public health to describe a situation in which the more people in a community immune to a particular pathogen, the fewer people available for that pathogen to infect. As the infectious agent spreads through a community, it has more trouble finding susceptible people if most of those around them are immune. In this manner, we rely on herd immunity for viruses, such as measles, rubella, polio, and chickenpox, among others, even if we are not having conversations about it. Influenza is more difficult because the virus changes so much from one year to the next and as such, vaccination does not offer long-term protection.

Related to COVID-19, herd immunity has been discussed more frequently for a couple of reasons. First, because this is a completely new virus, virtually no one has existing immunity. People can become immune to SARS-Co-V2, the virus that causes COVID-19, in two ways - through disease or through vaccination. Conversations have been about both of these concepts:

As vaccines are developed, one way to describe how well a vaccine works is to describe how many people would need to be immunized to achieve herd immunity.

Likewise, some people are talking about herd immunity because they want to get back to "normal" and are arguing to "make the herd immune" by just going about one's business and letting people get infected. Unfortunately, there are dangers involved with this because:

The disease is more fatal than a virus like influenza

We don't know who will become severely ill if infected

If too many people get sick at the same time, we will overwhelm medical resources

We don't know everything we need to know about how long immunity lasts following infection; we don't understand the long-lasting effects of infection; and we have limited treatments at this stage (although we are learning more every day)

Herd immunity can only be induced by vaccination. Never in history has any virus infection been eliminated because of immunity induced by natural infection.

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While COVID-19 vaccines have been developed more quickly than has ever been done in the past, it was imperative that speed did not decrease safety.

In this case, the timeline was shortened without sacrificing quality by:

Skipping phase I or combining phase I with phase II trials - Since phase I studies include a small number of people and evaluate whether the candidate vaccine causes an immune response and is safe, scientists could look at data from a group of people as phase II was progressing to make these evaluations.

Manufacturing "at risk" - While completing the large phase III clinical trials, manufacturers began producing the vaccine, so that if it was shown to be safe and effective, they would have large numbers of doses ready. The reason this is not typically the approach is because if the vaccine does not work, the manufacturer will have spent a significant amount of money to produce something that needs to be thrown away.

Support efforts - While waiting for a vaccine to be ready, many other aspects of vaccine delivery were prepared, including:

Developing plans for how to distribute the first, limited quantities available

Ensuring adequate supplies for distributing and administering vaccine, like vaccine vials, syringes and other equipment needed to vaccinate

Establishing mechanisms for distribution to large subsets of the population, especially in countries in which mechanisms may not currently be in place. For example, many countries do not have standard programs for vaccinating older adults. So, planning how to reach those people, without unintentionally exposing them to a crowd in which the virus may be spread, was something that could be planned during vaccine development.

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Some have proposed that giving people a live weakened vaccine, such as MMR (measles, mumps, and rubella) vaccine, might lessen the severity of coronavirus disease, including swelling in the lungs and sepsis, an infection in the bloodstream. While there is some evidence that live weakened vaccines can induce immunity that can protect against other infections, any protection would not be specific. At this time, use of MMR, or any other live weakened vaccine, has not been studied as a way to prevent the complications of coronavirus in either animals or people, so it is not recommended. Further, because the protection would not be specific or long-lived, it would not be as useful as COVID-19 vaccines.

For more information about MMR vaccine, go to " A Look at Each Vaccine: Measles, Mumps and Rubella (MMR) Vaccine."

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COVID-19 vaccines do not contain microchips. This idea is based on a false narrative and misinformation campaign waged online. You can find out more about where this idea came from on snopes.com.

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A baby's vaccines should not be anticipated to protect the baby from COVID-19. So, when trying to decide when it may be safe for family to meet the baby during COVID, parents should not rely on other vaccinations as a source of protection. While some have hypothesized that other vaccines may be protective, this protection would not be specific to COVID-19, and no studies have actually been completed to test this theory.

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No cure for coronavirus is available.

People who are mildly ill and recovering at home
Rest and drinking plenty of fluids are most important for people with mild cases of COVID-19. While over-the-counter medications can be used to make a person more comfortable, it is important to realize that often symptoms are the result of the immune response to infection. For example, fevers make the body a less "comfortable" environment for the virus to reproduce and allow the immune system to work better. So, treating fever can prolong illness. To learn more about fever, check out this downloadable question-and-answer sheet, or to find out more about fever and vaccines, check out this webpage.

Those recovering at home should be in touch with their healthcare provider for specific medical recommendations, and a nyone having trouble breathing, or who quickly takes a turn for the worse, should seek immediate medical care. A monoclonal antibody treatment, called bamlanivimab, was recently approved for treatment of mild-to-moderate disease in those with high risk conditions.

It is also important for those with mild illness to still isolate from others in the home as they can still spread the virus.

People who are severely ill and require hospitalization
Healthcare providers have been learning more about ways to treat people who become severely ill. One medication, Remdesivir, has been shown to shorten the length of infection. Similarly, a drug called dexamethasone (a steroid) has been shown to be of benefit for people with pneumonia caused by SARS-CoV-2.

Treatment of hospitalized patients varies based on the symptoms and complications each patient experiences.

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In late 2019, a novel coronavirus, SARS-CoV-2, formed. This new virus had two important characteristics. First, it could cause severe disease and death in people. Second, it could easily spread from one person to another. Together with the fact that no one in the world was immune, these characteristics set the stage for the COVID-19 pandemic that quickly changed current life as we knew it.

As scientists around the world have diligently worked to help us understand this virus and the disease it causes, it is important to realize that we will continue to learn more about this virus for many years to come. But, we have learned some important things already:

For many people, disease will be mild. Some people will not experience any detectable symptoms. But, this is not true for everyone, and, as with other infections, science has not evolved to a point that we can predict who will become severely ill, experience complications, or die. This means, everyone should take the virus seriously - if not for themselves, then for those around them.

In some cases, groups of people are known to be at greater risk of suffering severe COVID-19. These include older adults and people of color as well as sub-groups of the population, like those with heart and lung disease, obesity, type-2 diabetes, and pregnant women.

And, for some people symptoms last extremely long, and lingering, long-term effects may also result, although this is another area that healthcare providers and scientists are still working to understand.

Finally, while healthcare providers are learning more every day about how to treat COVID-19, many medications and treatments are still being studied.

For these reasons, and because prevention is better than treatment, COVID-19 vaccines are essential to returning to some sense of normalcy. But, we can also work together using important public health practices to limit the illness, deaths, and societal damage SARS-CoV-2 seeks to sow.

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Coronaviruses spread through respiratory secretions, like saliva produced during coughing, speaking, and singing, and nasal secretions producing during sneezing or from a runny nose. Droplets from coughs or sneezes are often considered "large droplets," meaning they don't hang in the air for long. But, in some cases, small virus-containing droplets can remain in the air for longer periods of time. These are sometimes referred to as "aerosolized droplets," and they are more contagious. Viruses present in either of these sized droplets can enter another person's eyes, nose, or mouth and infect cells that line that person's nose, throat, lungs, blood vessels, and intestines. As such, we can protect ourselves and decrease spread in these ways:

Handwashing - Because we touch so many things, we almost always have germs on our hands. If these viruses or bacteria are still infectious, we can easily inoculate ourselves, particularly if we touch our eyes, noses, or mouths with unclean hands.

Social distancing - Because respiratory droplets travel some distance after leaving our mouths or noses, staying further apart decreases the chance for particles containing viruses to then be breathed in or land on us. The speed and force with which a particle leaves the body determines how far it can travel before landing somewhere. So, droplets from a sneeze will travel further than those spread during speaking. While a particular distance is not guaranteed to protect someone, the Centers for Disease Control and Prevention (CDC) has recommended 6 feet. In enclosed spaces, like small rooms or cars, the chance for exposure increases; therefore, it is important to increase ventilation, by opening windows and not using recirculated air when possible.

Masks - While masks have been somewhat controversial, they do help to decrease the spread of this virus, particularly because it can spread through "small droplets," which means you do not need to see the droplets for them to spread the virus. Masks primarily decrease the spread of virus by the person wearing them, but they may also somewhat reduce the chance of being infected.

Find out more about masks:
How to properly put on, take off, and clean masks, October 2020 Parents PACK
Images of correct and incorrect ways to wear masks as well as information about studies of different mask materials, Vaccine Makers Project News & Events, September 30, 2020

Disinfecting surfaces - When respiratory droplets land on surfaces, the viruses they carry remain infectious for hours to days, depending on the characteristics of the virus, the type of surface on which they land, and the surrounding environment. Because the virus can be spread in droplets not visible to the eye, regularly cleaning surfaces that are touched often or around which people often pass is important to decreasing viral spread.

Staying home when sick - As with other respiratory viruses, anyone with symptoms should stay away from others to decrease spread. If someone with symptoms coughs or sneezes, their respiratory secretions are likely to have even greater amounts of virus than someone without symptoms. Therefore, they may infect more people or the small number of people they infect may get a bigger inoculation, which could lead to more severe disease. In the case of COVID-19, people who know (or think) they have been exposed are also being asked to isolate because it is estimated that about 4 of 10 people who are infected do not develop symptoms.

Last updated 12/15/2020

To see whether a vaccine works, scientists have to determine whether people who got the vaccine are less likely to get sick with the disease than those who were not vaccinated. They can do this in one of two ways:

If the pathogen is spreading in the community, they can see if fewer vaccinated people get sick.

But, if the pathogen is only spreading at low levels, they may not be able to tell because differences between vaccinated and unvaccinated people could simply be due to differences in exposure to the virus. In this situation, challenge studies can be used.

A "challenge study" is one that includes intentional exposure to the pathogen as part of the research plan. For example, a study volunteer might get vaccinated and a month after receiving the last dose be intentionally exposed to the pathogen. After exposure, the volunteer would be monitored for both symptoms of illness and the presence of a memory immune response, such as through the measurement and typing of antibodies in a blood sample. Challenge studies have been used in the past to determine the effectiveness of various influenza vaccines.

Challenge studies offers a few benefits:

As mentioned, they do not need to rely on disease spreading in the community to see whether the vaccine works.

Scientists know when the person was exposed to the pathogen.

They can control the exposure, so that the person is not likely to get severely ill if the vaccine did not work as expected.

However, challenge studies can have ethical and technological drawbacks that must be considered before being implemented:

By definition, this kind of study means volunteers are being intentionally exposed to a pathogen. If the vaccine does not work, some people could become severely ill, or even die.

Currently, for COVID-19, we have limited treatment options, so treating anyone from a study who becomes ill would be further hindered by these limits.

Scientists have an important responsibility when they choose the challenge strain of the pathogen. They need to choose a strain that will cause the immune system to respond, but not one that will cause severe illness. In the current COVID-19 situation, much remains to be learned about this pathogen, which complicates the choice of a challenge strain.

Also, under natural conditions, people will be exposed to different burdens of virus. As a general rule, the greater the amount of virus the worse the symptoms. Challenge studies, however, are likely to use only one dose of virus.

Watch this short video in which Dr. Offit discusses challenge studies.
Last updated 12/15/2020

Vaccine development typically follows a progression of increasingly larger studies to limit risk while learning about the potential vaccine. Every phase monitors safety of the potential vaccine, but each phase also has additional specific goals:

Phase I studies typically include fewer than 100 healthy adults and are designed to figure out if the potential vaccine generates an immune response. Watch a short CNN interview in which Dr. Offit discussed how to think about Phase I results (July 21, 2020).

Phase II studies typically include a few hundred healthy adults and are designed to figure out the optimal vaccine dose and vaccine production specifications and tests.

Phase III studies typically include tens of thousands of participants. Ideally, these participants represent the population of people who will be recommended to get the vaccine. These studies evaluate whether the vaccine works in the intended population, and because of the number of people who receive the potential vaccine, they are important for detecting side effects that may occur infrequently, and, therefore, might not have been found in the earlier phases. These are the last studies completed before a potential vaccine can be licensed. Early phase III trials of the COVID-19 vaccine were designed to include about 20,000 people who got the vaccine and 10,000 people who get a shot that doesn't contain the vaccine (i.e., a placebo). Some companies, however, might do smaller phase III trials.

After approval, scientists continue to monitor vaccines in "post-licensure studies." In this way, they can quickly become aware of any previously undetected issues of concern, so that vaccinations can be halted if necessary. The Vaccine Safety Datalink in the United States is designed to quickly pick up a safety problem once the vaccine has been administered to hundreds of thousands or millions of people.

For more details about each of these phases, visit the VEC's webpage, "Making Vaccines: Process of Vaccine Development."

For more details about the Vaccine Safety Datalink, visit the CDC's webpage, "Vaccine Safety Datalink (VSD)."

Last updated 12/15/2020

The amount of time for each phase of vaccine development varies based on a variety of factors related to the vaccine being tested, the disease, and the way the studies are designed. But, generally speaking, phase I trials take about 1 to 2 years, phase II trials take 2 or more years, and phase III trials take 3 to 4 years to complete.

In the case of COVID-19 vaccines, this timeline was shortened by combining the phases of trials, decreasing the number of participants in the early phases of the trials, and adding tremendous resources to allow for faster completion. For example, the government invested in some of the potential vaccine candidates to allow for building the manufacturing facilities and making vaccine doses before it is was known whether the vaccine worked. For example, because the Pfizer mRNA vaccine worked and was safe, doses could be distributed shortly after the vaccine was approved for use, but if the vaccine did not work, the doses would have been discarded.

You can find out more here:

Last updated 12/15/2020

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People make mRNA all the time. In our cells, DNA in the nucleus is used to make mRNA, which is sent to the cytoplasm where it serves as a blueprint to make proteins. Most of the time, the proteins that are produced are needed to help our bodies function.

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Will you get a text from your doctor? Will you read about it online? Or will you have to check the Centers for Disease Control and Prevention website to know when it's your turn in line?

As COVID-19 vaccines roll out to limited groups of people across the United States, how people learn they are eligible to get their shots won't be as clear while supplies remain limited, according to public health and policy experts and state vaccination plans.

"I think it's going to be a little bit murky," said Katie Greene, a visiting policy associate at the Duke-Margolis Center for Health Policy.

"I wouldn't be surprised if thousands of individuals get left out because of the information gap," added Tinglong Dai, a Johns Hopkins Carey Business School professor who studies operations management and business analytics in health care.

Vaccine rollout has largely been left to the states, and with an "isolated and decentralized health system" in the U.S., as Dai put it, people may not know when they're eligible to get their vaccine. And they may have to be proactive in finding where they can get one and in proving that they meet the criteria to be next in line.

In Phase 1a of the vaccine rollout, health care workers and residents of long-term care facilities are prioritized, easy groups to reach because they're in distinct locations, Greene said.

During the next phase, people 75 and older and front-line essential workers should be prioritized, according to recommendations from the CDC's Advisory Committee on Immunization Practices. After that, Phase 1c will include people 65 to 74 and people 16 to 64 who have high-risk medical conditions, along with other essential workers.

"These are groups that are much harder to reach," Greene said.

Dai expects there to be some confusion and inefficiency as distribution continues in late winter and early spring, when supply is still growing and more, but not all, people are eligible to get a vaccine.

"It's going to be a very complicated triage process," he said, adding that it won't be consistent across health care providers.
USA TODAY vaccine panel: The US has nailed the science behind the COVID vaccine. Next up: logistics and trust.
Federal officials with Operation Warp Speed hope that around 50 million people will have received their first of two shots of a COVID-19 vaccine by the end of January, Health and Human Services Secretary Alex Azar said earlier this week.

Two vaccines, one produced by Pfizer and BioNTech and another by Moderna, have already received emergency use authorization from the U.S. Food and Drug Administration. A Phase 3 clinical trial for the Johnson & Johnson vaccine has completed enrollment, and another vaccine candidate from AstraZeneca and Oxford University is expected to follow a few weeks later.

Azar has said the government should have enough supply so that every American who wants a vaccine can get it by summer 2021.

In the middle stages of rollout, state and local public health officials will have a lot of work to do to clearly define and communicate who is eligible, said John Brownstein, chief innovation officer at Boston Children's Hospital.

"At the state level, there are going to be important nuances in terms of eligibility," Brownstein said.

"Everyone wants to know their place in line. I think people will be tuned in."

Preregistration, eligibility websites and emails

The federal government has left it up to states to implement mass vaccination programs. Like many other policy decisions in the pandemic - from testing protocols to restrictions - states will have to tailor their vaccine rollouts to their specific needs, including how they communicate eligibility, Greene said.

State vaccine distribution plans submitted to the CDC earlier this year broadly cover how states will communicate with their residents, and the plans vary on how eligible people will be informed.

Right now, health care workers getting vaccinated find out through their employer, the facilities that are providing the vaccine. CVS and Walgreens are planning to go into tens of thousands of long-term care facilities to provide initial doses to residents and staff.

Many states' plans say they will rely on traditional media campaigns and mention press conferences from governors, outreach to community groups, and text and email campaigns.

As vaccine becomes more available, New York's plan says its residents will also be to check a website for a "vaccine eligibility screening tool and a vaccine administration site locator."

The health department websites in Colorado and Virginia have trackers that show they're still in Phase 1a of rollout.

In Maryland, residents will be able preregister for the vaccine through the state's existing immunization information system, the state plan says. The department of health will send targeted texts and emails to preregistered individuals who have not yet received their vaccine.

Greene said Maryland's preregistration plan is "a pretty innovative approach" but will rely on how many people can use the system.

Online systems for informing people of eligibility are only as good as the buy in, Dai said. For example, a hospital may be using a record system, like MyChart, to send alerts to people that they are eligible. But if a patient never set up their MyChart, they may not find out unless they reach out.
Side effects, differences and immunity: What to know about the COVID-19 vaccines in the US
"The central problem is we do not have a national waiting list for vaccination, and we do not even have that for individual states or counties," Dai said, comparing it to the national registry for organ donations.

As rollout expands, the CDC's playbook on vaccine distribution says it will also develop a screening tool for people to determine their own eligibility. That tool will then point them to VaccineFinder.org, an existing platform that connects the public to information about where they can get seasonal flu vaccines, vaccines for travel and other routinely recommendation vaccines.

Brownstein, who led the development of VaccineFinder.org, said the tool will play an important role in helping people find a vaccine once they learn they're eligible. He expects COVID-19 vaccine information will be available on the website starting in early 2021.

In November, the Department of Health and Human Services also announced that it would partner with pharmacy chains around the U.S. to provide vaccine as supplies become more available. That partnership is expected to cover 60% of pharmacies throughout the U.S., HHS said.
More: COVID-19 immunizations are going 'slower' than expected, officials say
CVS said in a statement that the public will be able to make appointments to get the vaccine at their pharmacies online or via an 800 number once the vaccine is more widely available.

"We will be promoting availability and raising awareness through multiple channels as we get closer to the timeframe, and dates and prioritization are determined," Mike DeAngelis, senior director for corporate communications at CVSHealth, told USA TODAY in an email.

'It's stuff we're going to have to figure out in a hurry'

As rollout enters the next phases, some states, however, may lag behind others, complicating the picture of who is eligible at a given time.

Vaccines are allocated according to the number of adults in each state, but that doesn't mean it will correlate with the number of high-risk people there.

A USA TODAY analysis published this week found which states fair best because they have fewer residents in high-risk categories and which states may lag, still vaccinating health care workers as others move forward to a wider population.
Tips How to persuade someone to take the COVID-19 vaccine
Greene and Brownstein said it'll be on the state and local public health officials to define who falls into each phase to lessen confusion.

"There will be some gray areas and professions where it's not clear what group you fit into," Brownstein said.

Having employers facilitate the process will make those gray areas more straightforward, Greene said, but challenges may persist, especially in smaller work settings with less outreach.

Similar issues could arise as it relates to underlying conditions and comorbidities. Someone's age is easily verifiable for pharmacies and vaccination clinics, but an underlying condition that puts someone at increased risk for COVID-19 complications may not be, Greene said.

Dai described a scenario where someone has received care in hospital system for an underlying condition but has since moved and plans to get their vaccine from another hospital. If those hospitals use different online records that don't easily communicate with each other, it could be on the individual to do their own outreach.

"There's going to have to be some level of expectation of some people not jumping the line," Brownstein added.

Whether someone would need a doctor's note to verify their condition would be a requirement that the vaccine provider would have to establish, but Greene said there would be a risk of increasing barriers and accessibility for people who may not have access to a primary care doctor.

"It's stuff we're going to have to figure out in a hurry," she said.

First responders such as firefighters, police

Teachers, support staff, day care workers

Food and agriculture workers

Manufacturing workers

Correction workers

U.S. Postal Service workers

Public transit workers

Grocery store workers

Who gets the vaccine first? Here's who the CDC recommends.

Obesity

Type 2 diabetes

COPD, or chronic obstructive pulmonary disease

Heart condition

Chronic kidney disease

Immunocompromised state from solid organ transplant

Sickle cell disease

Pregnancy

Smoker (current or with a history of smoking)

The CDC's Advisory Committee on Immunization Practices has recommended that phased vaccine rollout go to the following groups first:

Public health workers

Transportation and logistics workers

Food service workers

Construction workers

Finance workers

IT & Communications workers

Energy workers

Media workers

Legal workers

Public safety engineers

Water and wastewater workers

Contributing: Elizabeth Weise, Dennis Wagner, Donovan Slack and Aleszu Bajak Follow USA TODAY's Ryan Miller on Twitter @RyanW_Miller
Phase 1a: Front-line health care workers and people in long-term care facilities.

Phase 1b: People 75 and older and front-line essential workers, in the following categories:

Phase 1c: People 65 to 74, people 16 to 64 who have high-risk medical conditions, and other essential workers. The medical conditions listed are:

Workers in this category include:

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How will you be told when it's your turn for a COVID-19 vaccine? It's complicated.

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Will you get a text from your doctor? Will you read about it online? Or will you have to check the Centers for Disease Control and Prevention website to know when it's your turn in line?

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Published

Question

I have read that the vaccine causes infertility. That would be devastating. I guess it interferes with the formation of the placenta.

The COVID-19 mRNA vaccines now have been in tens of thousands of people and infertility has not been a problem for men or women.

Twenty-three women became pregnant after participating in Pfizer's mRNA vaccine clinical trial. Pfizer reported one poor pregnancy outcome in someone in the control/placebo group - meaning they had not received the vaccine.

There is a rumor that antibodies against the spike protein will also target a protein in the placenta of pregnant mothers, syncytin-1. There is no data suggesting that these antibodies will affect syncytin-1, as they are different proteins.

If there's a 98% chance I'll be ok if I get COVID-19, then why would I want a vaccine that is 95% effective? Am I missing something?

Read More

Which vaccines are closest to approval? And what does a mRNA vaccine do? Get these answers and more from epidemiologist David Brett-Major, MD, MPH.

Read More

Epidemiologist David Brett-Major, MD, MPH, shares how COVID-19 vaccine candidates are moving towards use in communities.

Read More

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You asked, we answered: Can mRNA vaccines cause infertility? | Nebraska Medicine Omaha, NE

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Published I have read that the vaccine causes infertility. That would be devastating. I guess it interferes with the formation of the placenta. The COVID-19 mRNA vaccines now have been in tens of thousands of people and infertility has not been a problem for men or women.

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See how to mitigate indoor COVID-19 transmission in different indoor spaces.

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The risk of catching coronavirus is much higher when dining inside a restaurant. Here's why people are still doing it.

Gabrie​la Bhaskar / The New York Times / REDUX

Thinking too hard about saliva can really ruin a nice meal. And to eat inside a restaurant in 2020 requires ignoring the harsh reality of drool: the residue left behind by a chip dipped in a shared bowl of guacamole, the flecks of spit flung loose by a drunken laugh, and the veritable makeout session that is sampling someone else's cocktail.

The unfortunate ubiquity of mucus is why restaurants, it brings me no pleasure to report, are contributing to the spread of the coronavirus. Indoor public places, including restaurants, played a significant role in the spread of COVID-19 this spring, according to scientific analyses of cellphone data. In a September study, people who tested positive for COVID-19 were more than twice as likely as those who tested negative to report eating in a restaurant recently. Talking with someone who has COVID-19 for 30 minutes or longer-about the time between your bloomin'-onion appetizer and molten-chocolate dessert-more than doubles your odds of catching it.

So why on earth would anyone eat inside a restaurant right now?

This is the question I mulled as I walked up and down the Crystal City strip in Virginia last week, dressed in a mask and an Ann Taylor sweater. I had journeyed to this chunk of suburban Washington, D.C., near the Pentagon, because, despite its concrete-y soullessness, it has the advantage of being home to several restaurants in a row. And they are popular restaurants-not your TGI Fridays, but not your two-tables-and-a-vegan-tagine either. In all, I approached and interviewed about a dozen random people as they walked out of restaurants in Crystal City, and later in another little patch of Northern Virginia called the Mosaic District, a mixed-use development off a giant highway.

These were not anti-mask COVID-19 deniers; people were clearly following the official rules. Nearly everyone on the street wore a mask, including the diners as soon as they exited their restaurant of choice. A man watching TV from the bar inside a Thai place had a mask on. So did the women walking down the street talking about their pharmacy-school applications.

Still, lots of people were eating indoors, even though it was a balmy, 66-degree night in early November. Unless you're extremely plugged into the public-health world, there's little reason you would pause before eating inside. Many of the places I passed had signs outside announcing We're Open! Like 44 other states as of this writing, Virginia hadn't banned eating indoors, even though the day after my interviews there were 14 coronavirus cases per 100,000 people in Fairfax County and 17 in Arlington. That's well over the 10-per-100,000 measure that Caitlin Rivers, an assistant professor at the Johns Hopkins Bloomberg School of Public Health, told me recently was her ceiling for socializing indoors with friends and family only.

Outside McCormick & Schmick's, a chain seafood place, I stopped three men who had just had a business dinner together. They refused to give me their full names, so I'll identify them by the color of their masks.

These three seemed relatively unconcerned about the virus. One of them, Red Mask, said he was still going to the gym; Blue Mask said he had gone to the barber recently and was impressed with how long his hairdresser spent wiping down his chair. (This is largely for show; surfaces are now thought to be less important to the spread of the virus than aerosols and droplets from other people). Black Mask told me that he was willing to go into any open restaurant. "I'm not in a high-risk category, so if I got it, it wouldn't bother me that much," he reasoned.

They asked me, somewhat aggressively, if I would eat inside a restaurant. I said I probably would not. And then of course I sounded weird, because why wouldn't you eat in a place that's open?

Each of us, to get through this terrible time, has clung to some coronavirus factoid or another that we believe protects us. Here's mine: The odds of catching the coronavirus are about 20 times higher indoors than outdoors. This year I have eaten on patios, in backyards, and on benches outside. But I haven't sat down inside a restaurant since March, and probably won't for many more months. "Indoor eating and bars and coffee shops are among the riskiest activities you can do. Outdoors is dramatically better," says Alex Huffman, an aerosols researcher at the University of Denver.

Several of the restaurant patrons I talked with didn't share this belief. One man, Steve Harris, even suggested that he was taking a bigger risk talking with me outdoors, with a mask on, than he was eating indoors, without a mask. (Our conversation was much less risky, but I felt awful nonetheless.) Think about when you're standing on a back patio at a friend's house, he said, just having a couple of beers, and the sun is setting. You can see peoples' spit glimmer as it flies out of their mouth into the twilight air. Disgusting, right? Probably more disgusting than having a Blue Creek cheeseburger at Ted's Montana Grill in November 2020. (Except that indoors, these speech droplets stay in the air for eight to 14 minutes. Not everyone would know this, because Donald Trump and his coronavirus advisers constantly spread incorrect information about the virus.)

Most people told me that they wouldn't eat at just any restaurant; they'd have to see "precautions" in place. Peoples' desired precautions ranged from the waitstaff wearing masks to air purifiers to seeing tables spaced apart with partitions separating them. One couple, told me, charmingly, that during the pandemic they will eat only in restaurants they are already "familiar with," as though knowing your way around a menu can protect you from an invisible virus.

The thing is, the precautions restaurants advertise aren't all very effective, according to experts. One woman who was dining out with her boyfriend told me that she likes to see temperature checks at restaurants. That makes sense, because retail establishments have been ostentatiously taking their patrons' temperatures for months now. But temperature checks are security theater; not everyone who has COVID-19 has a fever, and a fever can be caused by something other than COVID-19. Measures such as spacing tables apart and installing air purifiers can be helpful, experts told me, but they can't eliminate the risk entirely. Partitions don't do much, Huffman says: "They could actually help the aerosol pool on one side of it by disrupting the whole ventilation flow."

Near the Mosaic District, Silver Diner displayed a sign that claimed the establishment was Making Indoor Dining Like Outdoors, in part through the use of ultraviolet lights, both inside its HVAC system and beaming toward surfaces. Do Hyung Kim, who had just finished up a meal with his wife inside the diner, told me that the UV lights made him feel safer, since he had read about them in the newspaper. But two experts I spoke with said there's still not much evidence that UV lights prevent infection. "The data behind that is not definitive," said Tom Tsai, a health-policy professor at Harvard.

Why are people willing to risk it all for a T-bone? In general, humans tend to fall victim to " comparative optimism," in which we believe that bad things are more likely to happen to other people. There's still a relatively low likelihood of contracting COVID-19 during any given restaurant outing, but "people aren't particularly good at perceiving that kind of risk," says Toby Wise, a researcher at Caltech who has studied coronavirus risk perception.

People don't learn from statistics, such as cases per 100,000, but rather from their own experiences, says Maria Konnikova, a psychologist and the author of The Biggest Bluff, about the psychology of gambling. Eating at restaurants is comforting and familiar, which breeds "overconfidence and the downplaying of downside risk," she says. How could something so fun hurt us? Plus, it's not like authority figures are telling us to stay out of restaurants. "When there's a muddled message, you don't err on the side of safety," Konnikova says. "You err on the side of desire, especially if you're tired of quarantine."

Though some of my interviewees were drawn to the soft glow of a noodle joint because of their boredom at home or their desire for a date night, others were venturing out for the good of the restaurants themselves. With no additional coronavirus aid coming, "the money we just spent in there is gonna make sure that people are employed," a man named Mark told me in Crystal City. "It's absolutely important for all of us, if we're comfortable, that we should do that. Because I'll tell you what: The economy is our most important asset in our country." This is the bind the government has put us in: Risk your life to eat inside a beloved restaurant, or it might not exist when this is all over.

I asked all the people I spoke with whether they would be angry at government officials, the restaurant, or any other powers that be if they caught COVID-19 from eating indoors. They all said they wouldn't be. After all, restaurants are just one of the many types of businesses that remain open; they could have contracted it anywhere.

In part because our leaders have let the virus spread uncontrolled, it sometimes seems like it is an unstoppable threat and, like the weather, there's not much you can do about it. That thinking can lead to a certain kind of fatalism. When I talked with Gabrielle Velasco and George Kosmidis, a young couple outside a Spanish restaurant called Jaleo, Kosmidis said he was still going into an office regularly. So "I think there's a level of risk no matter what you do," he said. Velasco added that she was nevertheless frustrated with the overall government pandemic response. If you think about it, she said, the service staff, who work in close quarters all day, is taking on a bigger risk than the diners are. Why not risk a little when other people are risking so much?

Reached for comment about the state's indoor-dining situation, a spokesperson for Virginia Governor Ralph Northam said he "is working closely with state and local health experts, and he will continue to base his decisions in data, science, and public health." A few days after my interviews, Northam announced that he would require restaurants to stop serving alcohol after 10 p.m. and to close by midnight. Of course, how much time people spend inside restaurants before then is still entirely up to them.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

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The risk of catching coronavirus is much higher when dining inside a restaurant. Here's why people are still doing it. Thinking too hard about saliva can really ruin a nice meal.

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As restaurants gear up to extend outdoor dining in colder parts of the country, many are seating guests in enclosed and sometimes heated structures. But when it comes to virus transmission, is eating in covered outdoor setups less risky than inside?

The bottom line

As...

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How Covid-Safe Is Dining in a Restaurant's Outdoor Tent?

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As restaurants gear up to extend outdoor dining in colder parts of the country, many are seating guests in enclosed and sometimes heated structures. But when it comes to virus transmission, is eating in covered outdoor setups less risky than inside? The bottom line As...

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Sakis Mitrolidis / AFP / Getty

Updated at 1:17 p.m. ET on October 1, 2020
There's something strange about this coronavirus pandemic. Even after months of extensive research by the global scientific community, many questions remain open.

Why, for instance, was there such an enormous death toll in northern Italy, but not the rest of the country? Just three contiguous regions in northern Italy have 25,000 of the country's nearly 36,000 total deaths; just one region, Lombardy, has about 17,000 deaths. Almost all of these were concentrated in the first few months of the outbreak. What happened in Guayaquil, Ecuador, in April, when so many died so quickly that bodies were abandoned in the sidewalks and streets?* Why, in the spring of 2020, did so few cities account for a substantial portion of global deaths, while many others with similar density, weather, age distribution, and travel patterns were spared? What can we really learn from Sweden, hailed as a great success by some because of its low case counts and deaths as the rest of Europe experiences a second wave, and as a big failure by others because it did not lock down and suffered excessive death rates earlier in the pandemic? Why did widespread predictions of catastrophe in Japan not bear out? The baffling examples go on.

I've heard many explanations for these widely differing trajectories over the past nine months-weather, elderly populations, vitamin D, prior immunity, herd immunity-but none of them explains the timing or the scale of these drastic variations. But there is a potential, overlooked way of understanding this pandemic that would help answer these questions, reshuffle many of the current heated arguments, and, crucially, help us get the spread of COVID-19 under control.

By now many people have heard about R0-the basic reproductive number of a pathogen, a measure of its contagiousness on average. But unless you've been reading scientific journals, you're less likely to have encountered k, the measure of its dispersion. The definition of k is a mouthful, but it's simply a way of asking whether a virus spreads in a steady manner or in big bursts, whereby one person infects many, all at once. After nine months of collecting epidemiological data, we know that this is an overdispersed pathogen, meaning that it tends to spread in clusters, but this knowledge has not yet fully entered our way of thinking about the pandemic-or our preventive practices.
Read: Herd immunity is not a strategy
The now-famed R0 (pronounced as "r-naught") is an average measure of a pathogen's contagiousness, or the mean number of susceptible people expected to become infected after being exposed to a person with the disease. If one ill person infects three others on average, the R0 is three. This parameter has been widely touted as a key factor in understanding how the pandemic operates. News media have produced multiple explainers and visualizations for it. Movies praised for their scientific accuracy on pandemics are lauded for having characters explain the " all-important" R0. Dashboards track its real-time evolution, often referred to as R or Rt, in response to our interventions. (If people are masking and isolating or immunity is rising, a disease can't spread the same way anymore, hence the difference between R0 and R.)

Unfortunately, averages aren't always useful for understanding the distribution of a phenomenon, especially if it has widely varying behavior. If Amazon's CEO, Jeff Bezos, walks into a bar with 100 regular people in it, the average wealth in that bar suddenly exceeds $1 billion. If I also walk into that bar, not much will change. Clearly, the average is not that useful a number to understand the distribution of wealth in that bar, or how to change it. Sometimes, the mean is not the message. Meanwhile, if the bar has a person infected with COVID-19, and if it is also poorly ventilated and loud, causing people to speak loudly at close range, almost everyone in the room could potentially be infected-a pattern that's been observed many times since the pandemic begin, and that is similarly not captured by R. That's where the dispersion comes in.

There are COVID-19 incidents in which a single person likely infected 80 percent or more of the people in the room in just a few hours. But, at other times, COVID-19 can be surprisingly much less contagious. Overdispersion and super-spreading of this virus are found in research across the globe. A growing number of studies estimate that a majority of infected people may not infect a single other person. A recent paper found that in Hong Kong, which had extensive testing and contact tracing, about 19 percent of cases were responsible for 80 percent of transmission, while 69 percent of cases did not infect another person. This finding is not rare: Multiple studies from the beginning have suggested that as few as 10 to 20 percent of infected people may be responsible for as much as 80 to 90 percent of transmission, and that many people barely transmit it.

This highly skewed, imbalanced distribution means that an early run of bad luck with a few super-spreading events, or clusters, can produce dramatically different outcomes even for otherwise similar countries. Scientists looked globally at known early-introduction events, in which an infected person comes into a country, and found that in some places, such imported cases led to no deaths or known infections, while in others, they sparked sizable outbreaks. Using genomic analysis, researchers in New Zealand looked at more than half the confirmed cases in the country and found a staggering 277 separate introductions in the early months, but also that only 19 percent of introductions led to more than one additional case. A recent review shows that this may even be true in congregate living spaces, such as nursing homes, and that multiple introductions may be necessary before an outbreak takes off. Meanwhile, in Daegu, South Korea, just one woman, dubbed Patient 31, generated more than 5,000 known cases in a megachurch cluster.
Read: The pastors already planning to rebel against future shutdowns
Unsurprisingly, SARS-CoV, the previous incarnation of SARS-CoV-2 that caused the 2003 SARS outbreak, was also overdispersed in this way: The majority of infected people did not transmit it, but a few super-spreading events caused most of the outbreaks. MERS, another coronavirus cousin of SARS, also appears overdispersed, but luckily, it does not-yet-transmit well among humans.

This kind of behavior, alternating between being super infectious and fairly noninfectious, is exactly what k captures, and what focusing solely on R hides. Samuel Scarpino, an assistant professor of epidemiology and complex systems at Northeastern, told me that this has been a huge challenge, especially for health authorities in Western societies, where the pandemic playbook was geared toward the flu-and not without reason, because pandemic flu is a genuine threat. However, influenza does not have the same level of clustering behavior.

We can think of disease patterns as leaning deterministic or stochastic: In the former, an outbreak's distribution is more linear and predictable; in the latter, randomness plays a much larger role and predictions are hard, if not impossible, to make. In deterministic trajectories, we expect what happened yesterday to give us a good sense of what to expect tomorrow. Stochastic phenomena, however, don't operate like that-the same inputs don't always produce the same outputs, and things can tip over quickly from one state to the other. As Scarpino told me, "Diseases like the flu are pretty nearly deterministic and R0 (while flawed) paints about the right picture (nearly impossible to stop until there's a vaccine)." That's not necessarily the case with super-spreading diseases.

Nature and society are replete with such imbalanced phenomena, some of which are said to work according to the Pareto principle, named after the sociologist Vilfredo Pareto. Pareto's insight is sometimes called the 80/20 principle-80 percent of outcomes of interest are caused by 20 percent of inputs-though the numbers don't have to be that strict. Rather, the Pareto principle means that a small number of events or people are responsible for the majority of consequences. This will come as no surprise to anyone who has worked in the service sector, for example, where a small group of problem customers can create almost all the extra work. In cases like those, booting just those customers from the business or giving them a hefty discount may solve the problem, but if the complaints are evenly distributed, different strategies will be necessary. Similarly, focusing on the R alone, or using a flu-pandemic playbook, won't necessarily work well for an overdispersed pandemic.

Hitoshi Oshitani, a member of the National COVID-19 Cluster Taskforce at Japan's Ministry of Health, Labour and Welfare and a professor at Tohoku University who told me that Japan focused on the overdispersion impact from early on, likens his country's approach to looking at a forest and trying to find the clusters, not the trees. Meanwhile, he believes, the Western world was getting distracted by the trees, and got lost among them. To fight a super-spreading disease effectively, policy makers need to figure out why super-spreading happens, and they need to understand how it affects everything, including our contact-tracing methods and our testing regimes.

There may be many different reasons a pathogen super-spreads. Yellow fever spreads mainly via the mosquito Aedes aegypti, but until the insect's role was discovered, its transmission pattern bedeviled many scientists. Tuberculosis was thought to be spread by close-range droplets until an ingenious set of experiments proved that it was airborne. Much is still unknown about the super-spreading of SARS-CoV-2. It might be that some people are super-emitters of the virus, in that they spread it a lot more than other people. Like other diseases, contact patterns surely play a part: A politician on the campaign trail or a student in a college dorm is very different in how many people they could potentially expose compared with, say, an elderly person living in a small household. However, looking at nine months of epidemiological data, we have important clues to some of the factors.

In study after study, we see that super-spreading clusters of COVID-19 almost overwhelmingly occur in poorly ventilated, indoor environments where many people congregate over time-weddings, churches, choirs, gyms, funerals, restaurants, and such-especially when there is loud talking or singing without masks. For super-spreading events to occur, multiple things have to be happening at the same time, and the risk is not equal in every setting and activity, Muge Cevik, a clinical lecturer in infectious diseases and medical virology at the University of St. Andrews and a co-author of a recent extensive review of transmission conditions for COVID-19, told me.

Read: I have seen the future-and it's not the life we knew

Cevik identifies "prolonged contact, poor ventilation, [a] highly infectious person, [and] crowding" as the key elements for a super-spreader event. Super-spreading can also occur indoors beyond the six-feet guideline, because SARS-CoV-2, the pathogen causing COVID-19, can travel through the air and accumulate, especially if ventilation is poor. Given that some people infect others before they show symptoms, or when they have very mild or even no symptoms, it's not always possible to know if we are highly infectious ourselves. We don't even know if there are more factors yet to be discovered that influence super-spreading. But we don't need to know all the sufficient factors that go into a super-spreading event to avoid what seems to be a necessary condition most of the time: many people, especially in a poorly ventilated indoor setting, and especially not wearing masks. As Natalie Dean, a biostatistician at the University of Florida, told me, given the huge numbers associated with these clusters, targeting them would be very effective in getting our transmission numbers down.

Overdispersion should also inform our contact-tracing efforts. In fact, we may need to turn them upside down. Right now, many states and nations engage in what is called forward or prospective contact tracing. Once an infected person is identified, we try to find out with whom they interacted afterward so that we can warn, test, isolate, and quarantine these potential exposures. But that's not the only way to trace contacts. And, because of overdispersion, it's not necessarily where the most bang for the buck lies. Instead, in many cases, we should try to work backwards to see who first infected the subject.

Because of overdispersion, most people will have been infected by someone who also infected other people, because only a small percentage of people infect many at a time, whereas most infect zero or maybe one person. As Adam Kucharski, an epidemiologist and the author of the book The Rules of Contagion, explained to me, if we can use retrospective contact tracing to find the person who infected our patient, and then trace the forward contacts of the infecting person, we are generally going to find a lot more cases compared with forward-tracing contacts of the infected patient, which will merely identify potential exposures, many of which will not happen anyway, because most transmission chains die out on their own.

The reason for backward tracing's importance is similar to what the sociologist Scott L. Feld called the friendship paradox: Your friends are, on average, going to have more friends than you. (Sorry!) It's straightforward once you take the network-level view. Friendships are not distributed equally; some people have a lot of friends, and your friend circle is more likely to include those social butterflies, because how could it not? They friended you and others. And those social butterflies will drive up the average number of friends that your friends have compared with you, a regular person. (Of course, this will not hold for the social butterflies themselves, but overdispersion means that there are much fewer of them.) Similarly, the infectious person who is transmitting the disease is like the pandemic social butterfly: The average number of people they infect will be much higher than most of the population, who will transmit the disease much less frequently. Indeed, as Kucharski and his co-authors show mathematically, overdispersion means that "forward tracing alone can, on average, identify at most the mean number of secondary infections (i.e. R)"; in contrast, "backward tracing increases this maximum number of traceable individuals by a factor of 2-3, as index cases are more likely to come from clusters than a case is to generate a cluster."

Even in an overdispersed pandemic, it's not pointless to do forward tracing to be able to warn and test people, if there are extra resources and testing capacity. But it doesn't make sense to do forward tracing while not devoting enough resources to backward tracing and finding clusters, which cause so much damage.

Another significant consequence of overdispersion is that it highlights the importance of certain kinds of rapid, cheap tests. Consider the current dominant model of test and trace. In many places, health authorities try to trace and find forward contacts of an infected person: everyone they were in touch with since getting infected. They then try to test all of them with expensive, slow, but highly accurate PCR (polymerase chain reaction) tests. But that's not necessarily the best way when clusters are so important in spreading the disease.

PCR tests identify RNA segments of the coronavirus in samples from nasal swabs-like looking for its signature. Such diagnostic tests are measured on two different dimensions: Are they good at identifying people who are not infected (specificity), and are they good at identifying people who are infected (sensitivity)? PCR tests are highly accurate for both dimensions. However, PCR tests are also slow and expensive, and they require a long, uncomfortable swab up the nose at a medical facility. The slow processing times means that people don't get timely information when they need it. Worse, PCR tests are so responsive that they can find tiny remnants of coronavirus signatures long after someone has stopped being contagious, which can cause unnecessary quarantines.

Meanwhile, researchers have shown that rapid tests that are very accurate for identifying people who do not have the disease, but not as good at identifying infected individuals, can help us contain this pandemic. As Dylan Morris, a doctoral candidate in ecology and evolutionary biology at Princeton, told me, cheap, low-sensitivity tests can help mitigate a pandemic even if it is not overdispersed, but they are particularly valuable for cluster identification during an overdispersed one. This is especially helpful because some of these tests can be administered via saliva and other less-invasive methods, and be distributed outside medical facilities.

In an overdispersed regime, identifying transmission events (someone infected someone else) is more important than identifying infected individuals. Consider an infected person and their 20 forward contacts-people they met since they got infected. Let's say we test 10 of them with a cheap, rapid test and get our results back in an hour or two. This isn't a great way to determine exactly who is sick out of that 10, because our test will miss some positives, but that's fine for our purposes. If everyone is negative, we can act as if nobody is infected, because the test is pretty good at finding negatives. However, the moment we find a few transmissions, we know we may have a super-spreader event, and we can tell all 20 people to assume they are positive and to self-isolate-if there are one or two transmissions, there are likely more, exactly because of the clustering behavior. Depending on age and other factors, we can test those people individually using PCR tests, which can pinpoint who is infected, or ask them all to wait it out.

Read: The plan that could give us our lives back

Scarpino told me that overdispersion also enhances the utility of other aggregate methods, such as wastewater testing, especially in congregate settings like dorms or nursing homes, allowing us to detect clusters without testing everyone. Wastewater testing also has low sensitivity; it may miss positives if too few people are infected, but that's fine for population-screening purposes. If the wastewater testing is signaling that there are likely no infections, we do not need to test everyone to find every last potential case. However, the moment we see signs of a cluster, we can rapidly isolate everyone, again while awaiting further individualized testing via PCR tests, depending on the situation.

Unfortunately, until recently, many such cheap tests had been held up by regulatory agencies in the United States, partly because they were concerned with their relative lack of accuracy in identifying positive cases compared with PCR tests -a worry that missed their population-level usefulness for this particular overdispersed pathogen.

To return to the mysteries of this pandemic, what did happen early on to cause such drastically different trajectories in otherwise similar places? Why haven't our usual analytic tools-case studies, multi-country comparisons-given us better answers? It's not intellectually satisfying, but because of the overdispersion and its stochasticity, there may not be an explanation beyond that the worst-hit regions, at least initially, simply had a few unlucky early super-spreading events. It wasn't just pure luck: Dense populations, older citizens, and congregate living, for example, made cities around the world more susceptible to outbreaks compared with rural, less dense places and those with younger populations, less mass transit, or healthier citizenry. But why Daegu in February and not Seoul, despite the two cities being in the same country, under the same government, people, weather, and more? As frustrating at it may be, sometimes, the answer is merely where Patient 31 and the megachurch she attended happened to be.

Overdispersion makes it harder for us to absorb lessons from the world, because it interferes with how we ordinarily think about cause and effect. For example, it means that events that result in spreading and non-spreading of the virus are asymmetric in their ability to inform us. Take the highly publicized case in Springfield, Missouri, in which two infected hairstylists, both of whom wore masks, continued to work with clients while symptomatic. It turns out that no apparent infections were found among the 139 exposed clients (67 were directly tested; the rest did not report getting sick). While there is a lot of evidence that masks are crucial in dampening transmission, that event alone wouldn't tell us if masks work. In contrast, studying transmission, the rarer event, can be quite informative. Had those two hairstylists transmitted the virus to large numbers of people despite everyone wearing masks, it would be important evidence that, perhaps, masks aren't useful in preventing super-spreading.

Comparisons, too, give us less information compared with phenomena for which input and output are more tightly coupled. When that's the case, we can check for the presence of a factor (say, sunshine or Vitamin D) and see if it correlates with a consequence (infection rate). But that's much harder when the consequence can vary widely depending on a few strokes of luck, the way that the wrong person was in the wrong place sometime in mid-February in South Korea. That's one reason multi-country comparisons have struggled to identify dynamics that sufficiently explain the trajectories of different places.

Once we recognize super-spreading as a key lever, countries that look as if they were too relaxed in some aspects appear very different, and our usual polarized debates about the pandemic are scrambled, too. Take Sweden, an alleged example of the great success or the terrible failure of herd immunity without lockdowns, depending on whom you ask. In reality, although Sweden joins many other countries in failing to protect elderly populations in congregate-living facilities, its measures that target super-spreading have been stricter than many other European countries. Although it did not have a complete lockdown, as Kucharski pointed out to me, Sweden imposed a 50-person limit on indoor gatherings in March, and did not remove the cap even as many other European countries eased such restrictions after beating back the first wave. (Many are once again restricting gathering sizes after seeing a resurgence.) Plus, the country has a small household size and fewer multigenerational households compared with most of Europe, which further limits transmission and cluster possibilities. It kept schools fully open without distancing or masks, but only for children under 16, who are unlikely to be super-spreaders of this disease. Both transmission and illness risks go up with age, and Sweden went all online for higher-risk high-school and university students-the opposite of what we did in the United States. It also encouraged social-distancing, and closed down indoor places that failed to observe the rules. From an overdispersion and super-spreading point of view, Sweden would not necessarily be classified as among the most lax countries, but nor is it the most strict. It simply doesn't deserve this oversize place in our debates assessing different strategies.

Although overdispersion makes some usual methods of studying causal connections harder, we can study failures to understand which conditions turn bad luck into catastrophes. We can also study sustained success, because bad luck will eventually hit everyone, and the response matters.

The most informative case studies may well be those who had terrible luck initially, like South Korea, and yet managed to bring about significant suppression. In contrast, Europe was widely praised for its opening early on, but that was premature; many countries there are now experiencing widespread rises in cases and look similar to the United States in some measures. In fact, Europe's achieving a measure of success this summer and relaxing, including opening up indoor events with larger numbers, is instructive in another important aspect of managing an overdispersed pathogen: Compared with a steadier regime, success in a stochastic scenario can be more fragile than it looks.

Once a country has too many outbreaks, it's almost as if the pandemic switches into "flu mode," as Scarpino put it, meaning high, sustained levels of community spread even though a majority of infected people may not be transmitting onward. Scarpino explained that barring truly drastic measures, once in that widespread and elevated mode, COVID-19 can keep spreading because of the sheer number of chains already out there. Plus, the overwhelming numbers may eventually spark more clusters, further worsening the situation.

As Kucharski put it, a relatively quiet period can hide how quickly things can tip over into large outbreaks and how a few chained amplification events can rapidly turn a seemingly under-control situation into a disaster. We're often told that if Rt, the real-time measure of the average spread, is above one, the pandemic is growing, and that below one, it's dying out. That may be true for an epidemic that is not overdispersed, and while an Rt below one is certainly good, it's misleading to take too much comfort from a low Rt when just a few events can reignite massive numbers. No country should forget South Korea's Patient 31.

That said, overdispersion is also a cause for hope, as South Korea's aggressive and successful response to that outbreak-with a massive testing, tracing, and isolating regime-shows. Since then, South Korea has also been practicing sustained vigilance, and has demonstrated the importance of backward tracing. When a series of clusters linked to nightclubs broke out in Seoul recently, health authorities aggressively traced and tested tens of thousands of people linked to the venues, regardless of their interactions with the index case, six feet apart or not-a sensible response, given that we know the pathogen is airborne.

Perhaps one of the most interesting cases has been Japan, a country with middling luck that got hit early on and followed what appeared to be an unconventional model, not deploying mass testing and never fully shutting down. By the end of March, influential economists were publishing reports with dire warnings, predicting overloads in the hospital system and huge spikes in deaths. The predicted catastrophe never came to be, however, and although the country faced some future waves, there was never a large spike in deaths despite its aging population, uninterrupted use of mass transportation, dense cities, and lack of a formal lockdown.

It's not that Japan was better situated than the United States in the beginning. Similar to the U.S. and Europe, Oshitani told me, Japan did not initially have the PCR capacity to do widespread testing. Nor could it impose a full lockdown or strict stay-at-home orders; even if that had been desirable, it would not have been legally possible in Japan.

Oshitani told me that in Japan, they had noticed the overdispersion characteristics of COVID-19 as early as February, and thus created a strategy focusing mostly on cluster-busting, which tries to prevent one cluster from igniting another. Oshitani said he believes that "the chain of transmission cannot be sustained without a chain of clusters or a megacluster." Japan thus carried out a cluster-busting approach, including undertaking aggressive backward tracing to uncover clusters. Japan also focused on ventilation, counseling its population to avoid places where the three C's come together-crowds in closed spaces in close contact, especially if there's talking or singing-bringing together the science of overdispersion with the recognition of airborne aerosol transmission, as well as presymptomatic and asymptomatic transmission.

Oshitani contrasts the Japanese strategy, nailing almost every important feature of the pandemic early on, with the Western response, trying to eliminate the disease " one by one" when that's not necessarily the main way it spreads. Indeed, Japan got its cases down, but kept up its vigilance: When the government started noticing an uptick in community cases, it initiated a state of emergency in April and tried hard to incentivize the kinds of businesses that could lead to super-spreading events, such as theaters, music venues, and sports stadiums, to close down temporarily. Now schools are back in session in person, and even stadiums are open-but without chanting.

It's not always the restrictiveness of the rules, but whether they target the right dangers. As Morris put it, "Japan's commitment to 'cluster-busting' allowed it to achieve impressive mitigation with judiciously chosen restrictions. Countries that have ignored super-spreading have risked getting the worst of both worlds: burdensome restrictions that fail to achieve substantial mitigation. The U.K.'s recent decision to limit outdoor gatherings to six people while allowing pubs and bars to remain open is just one of many such examples."

Could we get back to a much more normal life by focusing on limiting the conditions for super-spreading events, aggressively engaging in cluster-busting, and deploying cheap, rapid mass tests -that is, once we get our case numbers down to low enough numbers to carry out such a strategy? (Many places with low community transmission could start immediately.) Once we look for and see the forest, it becomes easier to find our way out.
* This article originally stated that, in April, coronavirus deaths spiked in Quito, Ecuador. In fact, they spiked in Guayaquil, Ecuador.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

Zeynep Tufekci is a contributing writer at The Atlantic and an associate professor at the University of North Carolina. She studies the interaction between digital technology, artificial intelligence, and society.

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uninterrupted use of mass transportation

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This Overlooked Variable Is the Key to the Pandemic

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Updated at 1:17 p.m. ET on October 1, 2020 There's something strange about this coronavirus pandemic. Even after months of extensive research by the global scientific community, many questions remain open. Why, for instance, was there such an enormous death toll in northern Italy, but not the rest of the country?

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In the bleak ranking of worst COVID-19 outbreaks, the United States, with 7.2 million infections, is likely to be eclipsed only by India, which has 1 million fewer cases but is catching up fast.

Yet parts of India have led the world in one aspect of the pandemic response: contact tracing - the labor-intensive, time-sensitive, painstaking work of identifying people who were exposed to a known infected person.

Extensive contact tracing in two southern Indian states offers the strongest evidence yet that a few super-spreading individuals are responsible for a disproportionate share of new coronavirus infections, according to a study published Wednesday in the journal Science. It also suggests that children are more efficient transmitters of the virus than widely believed.

A team of Indian and U.S. researchers examined data from 575,071 individuals who were tested after coming into contact with 84,965 people with confirmed cases of COVID-19. That's an average of seven contacts per case, and a cohort more than 10 times larger than in a previous study from South Korea that mapped how the virus was transmitted.

"It's the largest epidemiological study anywhere on COVID by far," said the lead author, Ramanan Laxminarayan of the Center for Disease Dynamics, Economics and Policy, in New Delhi.

Laxminarayan and his colleagues found that just 8% of people with COVID-19 accounted for 60% of the new infections observed among the contacts. Meanwhile, 7 out of 10 COVID-19 patients were not linked to any new cases.

The finding underscores the essential role of super-spreaders in the COVID-19 pandemic: One individual or event, such as in a poorly ventilated indoor space, can trigger a high number of new infections, while others might not transmit the virus at all.

In the new study, researchers tracked down 78 people who had shared a bus or train with one of eight known infected people and sat within three rows of that person for more than six hours. Health workers visited these contacts at their homes to conduct follow-up screenings and determined that nearly 80% of them had contracted the coronavirus.

By contrast, people who were known to be exposed to infected individuals in lower-risk environments - such as being in the same room but more than three feet away - became infected only 1.6% of the time.

"Super-spreading events are the rule rather than the exception," Laxminarayan said. "It has lots of implications for modeling COVID, for how to keep places safe."

The study suggests that super-spreading events are influenced by behavior - that proximity to an infected person, length of contact and ambient conditions determine the level of risk. It doesn't examine whether some infected people spread the virus more efficiently because of biological factors, a question scientists are still trying to answer.

The results could help guide safety measures in places such as gyms, churches and choir practice spaces that have been locations for previous super-spreading events.

(Manish Swarup / Associated Press)

The study also found that although children younger than 17 were the least likely to die of COVID-19, they transmitted the virus at rates similar to the rest of the population, underscoring the idea that the disease doesn't spare young people. One data point in particular holds implications for reopening schools: Children ages 5 to 17 passed the virus to 18% of close contacts their own age.

Antonio Salas, a Spanish researcher who has investigated the role of super-spreaders in the pandemic, said the study's findings regarding children were important in light of "previous reports suggesting a minor role of children in the pandemic."

"National policies on how to proceed with children in schools and other social activities could change dramatically if the scientific evidence underpins the idea that children can infect as efficiently as adults, and even more, they could also behave as super-spreaders," said Salas, who was not involved in the India study.

As India's coronavirus caseload has doubled over the past month, from 3 million to more than 6 million, the study authors said their work showed one strength of the country's response: the ability to mobilize large numbers of health workers and civil servants to conduct contact tracing, identify high-risk individuals and closely track their cases.

The two Indian states in the study, Andhra Pradesh and Tamil Nadu, have a combined population of 128 million and boast some of the largest healthcare workforces and highest levels of public health spending in the country. Both turned to disease-surveillance networks put in place years ago during the AIDS epidemic to make house-to-house checks at levels unseen elsewhere in the world.

In Tamil Nadu, which includes the coastal metropolis of Chennai (formerly known as Madras), thousands of public and private healthcare workers were trained as contact tracers and health surveillance officers. The state had experience identifying at-risk populations from its battle against AIDS, which struck Tamil Nadu harder than almost anywhere else in the country.

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Once a person tested positive for the coronavirus, a public health worker interviewed them by phone about where they'd been and whom they'd met over the previous two weeks. Immediate family members were tested and isolated right away; others were located through phone calls and text messages.

Nearly all the contacts traced were people known to the infected person, so many strangers were missed. Still, in Chennai, health workers located and tested an average of 17 contacts per infected person through Aug. 1.

Although contact tracing is crucial to identifying, isolating and testing those vulnerable to infection - and helped countries such as South Korea avoid disastrous outbreaks - an effective system has eluded most of the U.S. because of shortages of trained staff and funding.

L.A. County's contact tracing program has failed to stop major outbreaks and been dogged by language barriers, slow turnaround times for test results and inaccurate information from patients. The county has hired about 2,600 contact tracers to cover a population of 10 million. Madurai, a semi-urban district in Tamil Nadu, had an equal number of health workers covering a population one-third the size, said Chandra Mohan, a state official who helped oversee the response and was a co-author of the study.

Although poorer nations now account for most of the world's COVID-19 cases, much of what is known about how the coronavirus is transmitted has come from relatively small-scale studies in China, the U.S. and the wealthy nations of Europe.

India imposed one of the strictest lockdowns anywhere in late March, measures that the new study found slowed the spread of the virus considerably. As Prime Minister Narendra Modi's government has eased restrictions to revive the economy, the disease, not surprisingly, has resurged. But Mohan said the contact tracing program saved lives.

Tamil Nadu has recorded nearly 600,000 infections and 9,400 deaths, which translates to 13 deaths per 100,000 people. The U.S. COVID-19 mortality rate is roughly 62 per 100,000.

"What is required is clarity of thought and the ability to mobilize resources and put them to use," Mohan said. "I suppose a good governance structure makes the difference between what can be done and what cannot be done."

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Largest study of COVID-19 transmission highlights essential role of super-spreaders

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In the bleak ranking of worst COVID-19 outbreaks, the United States, with 7.2 million infections, is likely to be eclipsed only by India, which has 1 million fewer cases but is catching up fast.

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Photo by vgajic via Getty Images

In a New York Times op-ed published Wednesday, writer Reyhan Harmanci details the "chaos" that ensued when her husband's cousin got results from a coronavirus test she'd taken days before hanging out maskless in Harmanci's yard: positive. (Harmanci had not known she had been tested.) Harmanci spent the next several days trying to figure out who all of the other people she'd recently spent time with could possibly have been infected by the cousin-a long list of family members, friends, and babysitters who cycled through her upstate backyard or otherwise socialized with her closely.

Harmanci characterizes the process of informing her guests, family, and friends of their potential exposure to COVID-19 as a task she finds unfair that she has to be responsible for, since the government has failed in terms of contact tracing and testing. (This is largely true, but, as someone pointed out on Twitter, the county where Harmanci's bustling backyard is located does have official contact tracers.) As she did this, Harmanci's child, suddenly ill with common kid-sickness symptoms that overlap with those of COVID-19, continued to see Harmanci's aging parents, who had been in close contact with her for days as they stayed at Harmanci's house for a vacation, and her family did not quarantine.

More so than pointing a finger at the systems that should be blamed for putting us in these positions, Harmanci uses the op-ed to abdicate the responsibility we have not only to ourselves, not only to those we love, but to those we don't know-under the very understanding that the government refuses to do it for us. It's amazing that it bears repeating at this stage of the pandemic, but: _It's still not safe to extensively hang out with many different people who don't live with you, including family members, maskless, especially if those people have recently traveled_-and, if you choose to anyway, you should be having a very in-depth conversation about recent behavior with whomever you see first.

Despite that everyone knows better as the pandemic rages on indefinitely, bending the rules to see, or even stay with, family and friends without masks (or while being otherwise lax about safety) is still very common across the country. In late July, the Washington Post reported that people who'd been going out to restaurants, bars, and jobs were infecting older, vulnerable family members they lived with at home. On Tuesday, Block Club Chicago published a report showing that gatherings among, specifically, close friends and family are driving up cases of coronavirus.

"I know that you feel safe when you are among friends that you know," said Allison Arwady, commissioner of Chicago's Department of Public Health. "It's easy to let your guard down, to not wear masks, to not social distance... As people are letting down their guard, they are out potentially contracting COVID and then bringing it back into households."

For a lot of people, wearing a mask and social distancing when around strangers in public is now a force of habit, and not a terribly difficult choice.

Still, some find it easier to view interactions at home, around friends and family they don't live with, as inherently safer-to let their guards down and choose to believe that everyone closest to them, emotionally speaking, is doing just fine.

In the past month alone, though:

It's understandable to want to trust family and friends and cave for a hug or a few hours mask-free. But all these little risks have the potential to spur much larger outbreaks, especially as schools begin to reopen all over the country.

As bioethicist Kelly Hills told VICE in mid-July, we often assume our friends are like us, that "what I think is risky is what they think is risky, and what they think is common sense is what I think is common sense. It just doesn't work like that," she said. Harmanci believed the people she knew were "doing the right thing," as she likely also believed of herself (even though she employed two different babysitters, had another friend over for lunch, went to the drive-in with a friend's family, and still let her high-risk parents stay in her home with her symptomatic baby).

The op-ed bemoans the lack of infrastructure and rules from elected leaders. While it's true that the U.S. is failing at contact tracing, quarantining, and sending clear, strong messages, Harmanci is either copping to a stunning level of ignorance here, or is lying to herself about her own responsibility. She and her family didn't attempt to get tested or utilize the state's contact tracing program. At one point after the baby gets sick, the grandmother takes the other child out for a walk around the neighborhood. "Should we be strictly quarantining now, no outside activities at all? What is paranoid and what is reasonable behavior?" Harmanci asks, as if the answer to those questions are still unknown.

Throughout the op-ed, Harmanci demonstrates a clear understanding of what's necessary to protect others. By inviting family over, potentially exposing networks of people to this virus, she's simply choosing not to follow them. It would be a lot more honest to admit that the "chaos" of this particular experience began the moment Harmanci decided that seeing "plenty of people," by her own admission, was acceptable at all, despite everything we know about how the pandemic spreads. Though as of her writing, no one else in her circle is sick, not everyone will be so lucky.

The kindest thing you can do for family members, friends, and loved ones who are keen on hanging out with inadequate regard for a global pandemic-the real "right thing"-is to tell them it isn't safe to get together yet. (Yes, still.) Harmanci could've told any of the people who wanted to pass through her backyard or stay in her home " no." Not out of rudeness, but out of necessity and, ultimately, out of love and respect. The feeling of hugging your grandma or having dinner with your cousin isn't worth getting them, yourself, or other people sick. There's no need to sow further chaos for one another than what we're already living through every day.

# data[].attributes.attachment_link.title
U.S. Coronavirus Outbreaks Are Increasingly Tied to Small Family Gatherings

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Photo by vgajic via Getty Images In a New York Times op-ed published Wednesday, writer Reyhan Harmanci details the "chaos" that ensued when her husband's cousin got results from a coronavirus test she'd taken days before hanging out maskless in Harmanci's yard: positive. (Harmanci had not known she had been tested.)

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Cite this: ACS Nano 2020 , 14 , 5 , 6339-6347

Copyright © 2020 American Chemical Society

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Note

The units in Figure 2 were corrected April 27, 2020.

The use of cloth masks, many of them homemade,(1,2) has become widely prevalent in response to the 2019-2020 SARS-CoV-2 outbreak, where the virus can be transmitted via respiratory droplets.(3−6) The use of such masks is also an anticipated response of the public in the face of future pandemics related to the respiratory tract. However, there is limited data available today on the performance of common cloth materials used in such cloth masks,(7−12) particularly their filtration efficiencies as a function of different aerosol sizes ranging from ∼10 nm to ∼10 μm scale sizes. This is also of current significance as the relative effectiveness of different droplet sizes in transmitting the SARS-CoV-2 virus is not clear, and understanding the filtration response across a large bracketed size distribution is therefore important.(13−16) In this paper, we report the results of experiments where we measure the filtration efficiencies of a number of common fabrics, as well as selective combinations for use as hybrid cloth masks, as a function of aerosol sizes ranging from ∼10 nm to 6 μm. These include cotton, the most widely used fabric in cloth masks, as well as fabric fibers that can be electrostatically charged, such as natural silk.

Respiratory droplets can be of various sizes(17,18) and are commonly classified as aerosols (made of droplets that are <5 μm) and droplets that are greater than 5 μm.(3) Although the fate of these droplets largely depends on environmental factors such as humidity, temperature, etc., in general, the larger droplets settle due to gravity and do not travel distances more than 1-2 m.(19) However, aerosols remain suspended in the air for longer durations due to their small size and play a key role in spreading infection.(14−16) The use of physical barriers such as respiratory masks can be highly effective in mitigating this spread via respiratory droplets.(20−22) Filtration of aerosols follows five basic mechanisms: gravity sedimentation, inertial impaction, interception, diffusion, and electrostatic attraction.(23,24) For aerosols larger than ∼1 μm to 10 μm, the first two mechanisms play a role, where ballistic energy or gravity forces are the primary influence on the large exhaled droplets. As the aerosol size decreases, diffusion by Brownian motion and mechanical interception of particles by the filter fibers is a predominant mechanism in the 100 nm to 1 μm range. For nanometer-sized particles, which can easily slip between the openings in the network of filter fibers, electrostatic attraction predominates the removal of low mass particles which are attracted to and bind to the fibers. Electrostatic filters are generally most efficient at low velocities such as the velocity encountered by breathing through a face mask.(25)

There have been a few studies reported on the use of cloth face masks mainly during or after the Influenza Pandemic in 2009;(8−12,26) However, there is still a lack of information that includes (i) the performance of various fabrics as a function of particle size from the nanoscale to the micron sized (particularly important because this covers the ∼10 nm to ∼5 μm size scale for aerosols) and (ii) the effect of hybrid multilayer approaches for masks that can combine the benefits of different filtering mechanisms across different aerosol size ranges.(9,26) These have been the objectives of the experimental work described in this paper. In addition, we also point out the importance of fit (that leads to gaps) while using the face mask.(27,28)

The experimental apparatus (see ) consists of an aerosol generation and mixing chamber and a downstream collection chamber. The air flows from the generation chamber to the collection chamber through the cloth sample that is mounted on a tube connecting the two chambers. The aerosol particles are generated using a commercial sodium chloride (NaCl) aerosol generator (TSI Particle Generator, model #8026), producing particles in the range of a few tens of nanometers to approximately 10 μm. The NaCl aerosol based testing is widely used for testing face respirators in compliance with the NIOSH 42 CFR Part 84 test protocol.(29,30) Two different particle analyzers are used to determine particle size dimensions and concentrations: a TSI Nanoscan SMPS nanoparticle sizer (Nanoscan, model #3910) and a TSI optical particle sizer (OPS, model #3330) for measurements in the range of 10 to 300 nm and 300 nm to 6 μm, respectively.

Figure 1

Particles are generated upstream of the cloth sample, whose filtration properties are to be tested, and the air is drawn through the cloth using a blower fan which can be controlled in order to vary the airflow rate. Effective area of the cloth sample during the tests was ∼59 cm ². Measurements of particle size and distribution were made by sampling air at a distance of 7.5 cm upstream and 15 cm downstream of the cloth sample. The differential pressures and air velocities were measured using a TSI digital manometer (model #AXD620) and a TSI Hot Wire anemometer (model #AVM410). The differential pressure (Δ P) across the sample material is an indicator of the comfort and breathability of the material when used as a face mask.(31) Tests were carried out at two different airflows: 1.2 and 3.2 CFM, representative of respiration rates at rest (∼35 L/min) and during moderate exertion (∼90 L/min), respectively.(32)

The effect of gaps between the contour of the face and the mask as caused by an improper fit will affect the efficiency of any face mask.(21,27,28,33) This is of particular relevance to cloth and surgical masks that are used by the public and which are generally not "fitted", unlike N95 masks or elastomeric respirators. A preliminary study of this effect was explored by drilling holes (symmetrically) in the connecting tube onto which the fabric (or a N95 or surgical mask) is mounted. The holes, in proximity to the sample (), resulted in openings of area ∼0.5−2% of the active sample area. This, therefore, represented "leakage" of the air around the mask.

Although the detailed transmission specifics of SARS-CoV-2 virus are not well understood yet, droplets that are below 5 μm are considered the primary source of transmission in a respiratory infection,(13,15,34) and droplets that are smaller than 1 μm tend to stay in the environment as aerosols for longer durations of up to 8 h.(19) Aerosol droplets containing the SARS-CoV-2 virus have been shown to remain suspended in air for ∼3 h.(13,35) We have therefore targeted our experimental measurements in the important particle size range between ∼10 nm and 6 μm.

We tested the performance of over 15 natural and synthetic fabrics that included materials such as cotton with different thread counts, silk, flannel, and chiffon. The complete list is provided in the section. For comparison, we also tested a N95 respirator and surgical masks. Additionally, as appropriate, we tested the efficiency of multiple layers of a single fabric or a combination of multiple fabrics for hybrid cloth masks in order to explore combinations of physical filtering as well as electrostatic filtering.

We determine the filtration efficiency of a particular cloth as a function of particle size () by measuring the concentration of the particles upstream, C u (a,b) and the concentration of the particle downstream, C d (c,d). Concentrations were measured in the size ranges of 10-178 nm (using the nanoscan tool) and 300 nm to 6 μm (using the optical particle sizer tool). The representative example in shows the case for a single layer of silk fabric, where the measurements of C u and C d were carried out at a flow rate of 1.2 CFM. Following the procedure detailed in the section, we then estimated the filtration efficiency of a cloth from C u and C d as a function of aerosol particle size.

Figure 2

The results plotted in a are the filtration efficiencies for cotton (the most common material used in cloth masks) with different thread counts (rated in threads per inch-TPI-and representative of the coarseness or fineness of the fabric). We compare a moderate (80 TPI) thread count quilter's cotton (often used in do-it-yourself masks) with a high (600 TPI) cotton fabric sample. Additionally, we also measured the transmission through a traditional cotton quilt where two 120 TPI quilter's cotton sheets sandwich a ∼0.5 cm batting (90% cotton-5% polyester-5% other fibers). Comparing the two cotton sheets with different thread counts, the 600 TPI cotton is clearly superior with >65% efficiency at <300 nm and >90% efficiency at >300 nm, which implies a tighter woven cotton fabric may be preferable. In comparison, the single-layer 80 TPI cotton does not perform as well, with efficiencies varying from ∼5 to ∼55% depending on the particle size across the entire range. The quilt, a commonly available household material, with a fibrous cotton batting also provided excellent filtration across the range of particle sizes (>80% for <300 nm and >90% for >300 nm).

Figure 3

Electrostatic interactions are commonly observed in various natural and synthetic fabrics.(36,37) For instance, polyester woven fabrics can retain more static charge compared to natural fibers or cotton due to their lower water adsorption properties.(36) The electrostatic filtering of aerosols have been well studied.(38) As a result, we investigated three fabrics expected to possess moderate electrostatic discharge value: natural silk, chiffon (polyester-Spandex), and flannel (cotton-polyester).(36) The results for these are shown in b. In the case of silk, we made measurements through one, two, and four layers of the fabric as silk scarves are often wrapped in multiple layers around the face (the results for two layers of silk are presented in Figure S1 (Supporting Information) and omitted from this figure). In all of these cases, the performance in filtering nanosized particles <300 nm is superior to performance in the 300 nm to 6 μm range and particularly effective below ∼30 nm, consistent with the expectations from the electrostatic effects of these materials. Increasing the number of layers (as shown for silk in b), as expected, improves the performance. We performed additional experiments to validate this using the 600 TPI cotton and chiffon ( Figure S1). We note that the performance of a four-layer silk composite offers >80% filtration efficiency across the entire range, from 10 nm to 6 μm.

In a, we combine the nanometer-sized aerosol effectiveness (for silk, chiffon, and flannel) and wearability (of silk and chiffon because of their sheer nature) with the overall high performance of the 600 TPI cotton to examine the filtration performance of hybrid approaches. We made measurements for three variations: combining one layer 600 TPI cotton with two layers of silk, two layers of chiffon, and one layer of flannel. The results are also compared with the performance of a standard N95 mask. All three hybrid combinations performed well, exceeding 80% efficiency in the <300 nm range, and >90% in the >300 nm range. These cloth hybrids are slightly inferior to the N95 mask above 300 nm, but superior for particles smaller than 300 nm. The N95 respirators are designed and engineered to capture more than 95% of the particles that are above 300 nm,(39,40) and therefore, their underperformance in filtering particles below 300 nm is not surprising.

Figure 4

It is important to note that in the realistic situation of masks worn on the face without elastomeric gasket fittings (such as the commonly available cloth and surgical masks), the presence of gaps between the mask and the facial contours will result in "leakage" reducing the effectiveness of the masks. It is well recognized that the "fit" is a critical aspect of a high-performance mask.(27,28,33,41) Earlier researchers have attempted to examine this qualitatively in cloth and other masks through feedback on "fit" from human trials.(11,12) In our case, we have made a preliminary examination of this effect via the use of cross-drilled holes on the tube holding the mask material (see ) that represents leakage of air. For example, in b, we compare the performance of the surgical mask and the cotton/silk hybrid sample with and without a hole that represents about ∼1% of the mask area. Whereas the surgical mask provides moderate (>60%) and excellent (close to 100%) particle exclusion below and above 300 nm, respectively, the tests carried out with the 1% opening surprisingly resulted in significant drops in the mask efficiencies across the entire size range (60% drop in the >300 nm range). In this case, the two holes were ∼0.635 cm in diameter and the mask area was ∼59 cm ². Similar trends in efficiency drops are seen in the cotton/silk hybrid sample, as well. Hole size also had an influence on the filtration efficiency. In the case of an N95 mask, increasing hole size from 0.5 to 2% of the cloth sample area reduced the weighted average filtration efficiency from ∼60 to 50% for a particle of size <300 nm. It is unclear at this point whether specific aerodynamic effects exacerbate the "leakage" effects when simulated by holes. Its determination is outside the scope of this paper. However, our measurements at both the high flow (3.2 CFM) and low flow (1.2 CFM) rates show substantial drop in effectiveness when holes are present. The results in - highlight materials with good performance. Several fabrics were tested that did not provide strong filtration protection (<30%), and examples include satin and synthetic silk ( Table S1). The filtration efficiencies of all of the samples that we measured at both 1.2 CFM and 3.2 CFM are detailed in the Supporting Information ( Figures S2-S4).

In , we summarize the key findings from the various fabrics and approaches that we find promising. Average filtration efficiencies (see section for further detail) in the 10-178 nm and 300 nm to 6 μm range are presented along with the differential pressures measured across the cloths, which represents the breathability and degree of comfort of the masks. The average differential pressure across all of the fabrics at a flow rate of 1.2 CFM was found to be 2.5 ± 0.4 Pa, indicating a low resistance and represent conditions for good breathability ().(31) As expected, we observed an increase in the average differential pressures for the higher flow rate (3.2 CFM) case ( Table S1).

Guidance

We highlight a few observations from our studies for cloth mask design:

Fabric with tight weaves and low porosity, such as those found in cotton sheets with high thread count, are preferable. For instance, a 600 TPI cotton performed better than an 80 TPI cotton. Fabrics that are porous should be avoided.

Materials such as natural silk, a chiffon weave (we tested a 90% polyester-10% Spandex fabric), and flannel (we tested a 65% cotton-35% polyester blend) can likely provide good electrostatic filtering of particles. We found that four layers of silk (as maybe the case for a wrapped scarf) provided good protection across the 10 nm to 6 μm range of particulates.

Combining layers to form hybrid masks, leveraging mechanical and electrostatic filtering may be an effective approach. This could include high thread count cotton combined with two layers of natural silk or chiffon, for instance. A quilt consisting of two layers of cotton sandwiching a cotton−polyester batting also worked well. In all of these cases, the filtration efficiency was >80% for <300 nm and >90% for >300 nm sized particles.

The filtration properties noted in (i) through (iii) pertain to the intrinsic properties of the mask material and do not take into account the effect of air leaks that arise due to improper "fit" of a mask on the user's face. It is critically important that cloth mask designs also take into account the quality of this "fit" to minimize leakage of air between the mask and the contours of the face, while still allowing the exhaled air to be vented effectively. Such leakage can significantly reduce mask effectiveness and are a reason why properly worn N95 masks and masks with elastomeric fittings work so well.

In conclusion, we have measured the filtration efficiencies of various commonly available fabrics for use as cloth masks in filtering particles in the significant (for aerosol-based virus transmission) size range of ∼10 nm to ∼6 μm and have presented filtration efficiency data as a function of aerosol particle size. We find that cotton, natural silk, and chiffon can provide good protection, typically above 50% in the entire 10 nm to 6.0 μm range, provided they have a tight weave. Higher threads per inch cotton with tighter weaves resulted in better filtration efficiencies. For instance, a 600 TPI cotton sheet can provide average filtration efficiencies of 79 ± 23% (in the 10 nm to 300 nm range) and 98.4 ± 0.2% (in the 300 nm to 6 μm range). A cotton quilt with batting provides 96 ± 2% (10 nm to 300 nm) and 96.1 ± 0.3% (300 nm to 6 μm). Likely the highly tangled fibrous nature of the batting aids in the superior performance at small particle sizes. Materials such as silk and chiffon are particularly effective (considering their sheerness) at excluding particles in the nanoscale regime (<∼100 nm), likely due to electrostatic effects that result in charge transfer with nanoscale aerosol particles. A four-layer silk (used, for instance, as a scarf) was surprisingly effective with an average efficiency of >85% across the 10 nm −6 μm particle size range. As a result, we found that hybrid combinations of cloths such as high threads-per-inch cotton along with silk, chiffon, or flannel can provide broad filtration coverage across both the nanoscale (<300 nm) and micron scale (300 nm to 6 μm) range, likely due to the combined effects of electrostatic and physical filtering. Finally, it is important to note that openings and gaps (such as those between the mask edge and the facial contours) can degrade the performance. Our findings indicate that leakages around the mask area can degrade efficiencies by ∼50% or more, pointing out the importance of "fit". Opportunities for future studies include cloth mask design for better "fit" and the role of factors such as humidity (arising from exhalation) and the role of repeated use and washing of cloth masks. In summary, we find that the use of cloth masks can potentially provide significant protection against the transmission of particles in the aerosol size range.

Materials

All of the fabrics used as well as the surgical masks and N95 respirators tested are commercially available. We used 15 different types of fabrics. This included different types of cotton (80 and 600 threads per inch), cotton quilt, flannel (65% cotton and 35% polyester), synthetic silk (100% polyester), natural silk, Spandex (52% nylon, 39% polyester, and 9% Spandex), satin (97% polyester and 3% Spandex), chiffon (90% polyester and 10% Spandex), and different polyester and polyester-cotton blends. Specific information on the composition, microstructure, and other parameters can be found in the Supporting Information ( Table S2).

Polydisperse Aerosol Generation

A polydisperse, nontoxic NaCl aerosol was generated using a particle generator and introduced into the mixing chamber along with an inlet for air. The aerosol is then mixed in the mixing chamber with the help of a portable fan. The particle generator produces particles sizes in the ranges of 10 nm to 10 μm.

Detection of Aerosol Particles

The particles were sampled both upstream ( C u, before the aerosol passes through the test specimen) and downstream ( C d, after the aerosol passes through the test specimen) for 1 min. The samples collected from the upstream and downstream are separately sent to the two particle sizers to determine a particle concentration (pt/cc). Each sample is tested seven times following the minimum sample size recommended by the American Industrial Hygiene Association exposure assessment sampling guidelines.(42) We observed a significantly lower particle count in the upper size distribution for both of the data sets, that is, for particles greater than 178 nm for the data from the TSI Nanoscan analyzer and greater than 6 μm for the data from TSI OPS analyzer. We exclude the data above these thresholds for all of the studies reported due to the extremely low counts. We categorize our data based on these two particle analyzers-individually the two plots (a,b) show two size distributions-particles smaller than 300 nm and particles larger than 300 nm. Two different flow rates of 1.2 CFM (a face velocity of 0.1 m/s) and 3.2 CFM (a face velocity of 0.26 m/s) were used that corresponded to rates observed at rest to moderate activity, respectively. The velocity of the aerosol stream was measured at ∼5 cm behind where the test specimen would be mounted using a velocity meter.

Differential Pressure

The differential pressure (Δ P) across the test specimen was measured ∼7.5 cm away on either side of the material being tested using a micromanometer. The Δ P value is an estimate of the breathability of the fabric.

Data Analysis

The particle concentrations from seven consecutive measurements were recorded and divided into multiple bins-10 for nanoparticle sizer (dimensions in nm: 10-13, 13-18, 18-24, 24-32, 32-42, 42-56, 56-75, 75-100, 100-133, 133-178) and 6 for optical particle sizer (dimensions in μm: 0.3-0.6, 0.6-1.0, 1.0-2.0, 2.0-3.0, 3.0-4.0, 4.0-6.0). The seven measurements for each bin were subjected to one iteration of the Grubbs' test with a 95% confidence interval to remove at most one outlier per bin. This improves the statistical viability of the data. Following Grubbs' test, average concentrations were used to calculate the filtration efficiencies as described below.

Filtration Efficiency

The filtration efficiency (FE) of different masks was calculated using the following formula: where C u and C d are the mean particle concentrations per bin upstream and downstream, respectively. To account for any possible drifts in the aerosol generation, we measured upstream concentrations before and after the downstream measurement and used the average of these two upstream values to calculate C u (for runs that did not include a gap). We do not measure upstream concentration twice when the run included a gap. The error in FE was calculated using the quadrature rule of error propagation. Due to noise in the measurements, some FE values were below 0, which is unrealistic. As such, negative FE values were removed from consideration in figures and further calculations. In addition to the FE curves, we computed an aggregate filter efficiency for each test specimen. To do this, we took a weighted average of FE values weighted by the bin width for the two particle size ranges (<300 nm and >300 nm). These values are reported in and Table S1.

The Supporting Information is available free of charge at https://pubs.acs.org/doi/10.1021/acsnano.0c03252.

Filtration efficiencies for various fabrics tested at two different flow rates and the effect of layering on the filtration efficiencies of chiffon, silk, and 600 TPI cotton; detailed information on various fabrics used ( PDF)

⊥Author Contributions

A.K. and A.P. contributed equally.

Department of Defense Vannevar Bush Fellowship Grant No. N00014-18-1-2869.

The authors declare no competing financial interest.

Terms & Conditions

Electronic Supporting Information files are available without a subscription to ACS Web Editions. The American Chemical Society holds a copyright ownership interest in any copyrightable Supporting Information. Files available from the ACS website may be downloaded for personal use only. Users are not otherwise permitted to reproduce, republish, redistribute, or sell any Supporting Information from the ACS website, either in whole or in part, in either machine-readable form or any other form without permission from the American Chemical Society. For permission to reproduce, republish and redistribute this material, requesters must process their own requests via the RightsLink permission system. Information about how to use the RightsLink permission system can be found at http://pubs.acs.org/page/copyright/permissions.html.

Use of the Center for Nanoscale Materials, an Office of Science user facility, was supported by the U.S. Department of Energy, Office of Science, Office of Basic Energy Sciences, under Contract No. DE-AC02-06CH11357. S.G. acknowledges the Vannevar Bush Fellowship under the program sponsored by the Office of the Undersecretary of Defense for Research and Engineering [OUSD (R&E)] and the Office of Naval Research as the executive manager for the grant. A.K. acknowledges and thanks Prof. Anindita Basu for helpful discussion and support.

This article references 42 other publications.

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Shakya, K. M. ; Noyes, A. ; Kallin, R. ; Peltier, R. E. Evaluating the Efficacy of Cloth Facemasks in Reducing Particulate Matter Exposure. J. Exposure Sci. Environ. Epidemiol. 2017, 352- 357, DOI: 10.1038/jes.2016.42 27,

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Electronic Code of Federal Regulations (eCFR), Title 42: Public Health, Part 84-Approval of Respiratory Protective Devices. Code of Federal Regulations, April 2020.

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Sanchez, A. L. ; Hubbard, J. A. ; Dellinger, J. G. ; Servantes, B. L. Experimental Study of Electrostatic Aerosol Filtration at Moderate Filter Face Velocity. Aerosol Sci. Technol. 2013, 606- 615, DOI: 10.1080/02786826.2013.778384 47,

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Bullock, W. H.; Ignacio, J. S. A Strategy for Assessing and Managing Occupational Exposures; AIHA Press, American Industrial Hygiene Association, 2006.

This article is cited by 10 publications.

1. Steven R. Lustig, John J. H. Biswakarma, Devyesh Rana, Susan H. Tilford, Weike Hu, Ming Su, Michael S. Rosenblatt. Effectiveness of Common Fabrics to Block Aqueous Aerosols of Virus-like Nanoparticles. ACS Nano 2020 , Article ASAP.

2. Nazek El-Atab, Nadeem Qaiser, Huda Badghaish, Sohail F. Shaikh, Muhammad Mustafa Hussain. Flexible Nanoporous Template for the Design and Development of Reusable Anti-COVID-19 Hydrophobic Face Masks. ACS Nano 2020 , Article ASAP.

Abstract

Figure 1

Figure 2

Figure 3

Figure 4

This article references 42 other publications.

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Shakya, K. M. ; Noyes, A. ; Kallin, R. ; Peltier, R. E. Evaluating the Efficacy of Cloth Facemasks in Reducing Particulate Matter Exposure. J. Exposure Sci. Environ. Epidemiol. 2017, 352- 357, DOI: 10.1038/jes.2016.42 27,

2. 17

Zhang, H. ; Li, D. ; Xie, L. ; Xiao, Y. Documentary Research of Human Respiratory Droplet Characteristics. Procedia Eng. 2015, 1365- 1374, DOI: 10.1016/j.proeng.2015.09.023 121,

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Sanchez, A. L. ; Hubbard, J. A. ; Dellinger, J. G. ; Servantes, B. L. Experimental Study of Electrostatic Aerosol Filtration at Moderate Filter Face Velocity. Aerosol Sci. Technol. 2013, 606- 615, DOI: 10.1080/02786826.2013.778384 47,

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Supporting Information

The Supporting Information is available free of charge at https://pubs.acs.org/doi/10.1021/acsnano.0c03252.

Filtration efficiencies for various fabrics tested at two different flow rates and the effect of layering on the filtration efficiencies of chiffon, silk, and 600 TPI cotton; detailed information on various fabrics used ( PDF)

Terms & Conditions

Electronic Supporting Information files are available without a subscription to ACS Web Editions. The American Chemical Society holds a copyright ownership interest in any copyrightable Supporting Information. Files available from the ACS website may be downloaded for personal use only. Users are not otherwise permitted to reproduce, republish, redistribute, or sell any Supporting Information from the ACS website, either in whole or in part, in either machine-readable form or any other form without permission from the American Chemical Society. For permission to reproduce, republish and redistribute this material, requesters must process their own requests via the RightsLink permission system. Information about how to use the RightsLink permission system can be found at http://pubs.acs.org/page/copyright/permissions.html.

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Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks

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The emergence of a pandemic affecting the respiratory system can result in a significant demand for face masks. This includes the use of cloth masks by large sections of the public, as can be seen during the current global spread of COVID-19.

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When socializing outside gets harder in much of the U.S., daily life will get more dismal, and the virus might spread even further.

Bruno Barbey / Magnum

Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

Throughout the pandemic, one lodestar of public-health advice has come down to three words: Do things outside. For nearly five months now, the outdoors has served as a vital social release valve-a space where people can still eat, drink, relax, exercise, and worship together in relative safety.

Later this year, that precious space will become far less welcoming in much of the U.S. "What do you do when nobody wants to go to the beach on some cold November day?" Andrew Noymer, a public-health professor at UC Irvine, said to me. "People are going to want to go to bowling alleys and whatnot, and that's a recipe for disaster, honestly-particularly if they don't want to wear masks."
From the September 2020 issue: How the pandemic defeated America
In recent interviews with Noymer and other experts, I caught glimpses of the winter to come, and what I saw was bleak, even compared with what Americans have already experienced. The winter will be worse-for the quality of daily life in America and, possibly, for the course of the pandemic itself.

"There really is no easy way to socialize during late fall [and] winter in large parts of the country if you're not doing it outside," Ashish Jha, the director of the Harvard Global Health Institute, told me. "Could I have people over in my house for two hours on a Sunday morning in December? Barring really good testing, probably not."

That's because the risk of spreading the coronavirus is heightened in enclosed spaces. Outdoors, there is enough air for the virus to be "rapidly diluted," as well as the helpful "virus-killing action of sunlight," explains Linsey Marr, an engineering professor at Virginia Tech. Indoors, she told me, "the virus can build up" and be more easily inhaled, and "if the space is heated, it can lead to dry air," which is more hospitable to the virus.

The experts I consulted were very concerned about the risks of indoor gatherings, but mentioned several measures that could make them safer if people decide to have them anyway: stay at least six feet apart, wear a mask, wipe down frequently touched surfaces, meet in a building with sufficient filters in its ventilation system, use a portable air purifier and a humidifier, and stay clear of crowded rooms. (If all of that sounds onerous, it's because spending time indoors with people you don't live with is really risky-and better avoided if you can help it.)
Read: We need to talk about ventilation
In places with chilly winter weather, the usual reprieves from the cold-cozy indoor gatherings and vacations to warmer climes-will come with significant risks, but going outside and meeting others will still be okay if people keep proper distance and wear a mask. "It may not be spreading a blanket in Central Park and having a picnic, but certainly there are outdoor activities that one can [do]," says David Vlahov, an epidemiologist at the Yale School of Nursing. Going on a walk with a friend or having a snowball fight seemed relatively safe to him. (He was not as keen on sledding with multiple passengers.)

Perhaps the safest way to gather in someone's home, as unpleasant as it might sound, is to make the indoors more like the outdoors. Marr told me that her family doesn't plan to have any guests inside their house during the pandemic, but may convene winter gatherings in their garage, with the "door open and a heat lamp, with hats and gloves and maybe bundled in sleeping bags." She also suggested getting together with people outdoors around a bonfire or under heat lamps.

Similarly, Jha told me that for close friends, he could imagine opening up the windows in his house and letting in fresh winter air in order to have them over. "It'll be painful for a couple of hours, but we'll sit and at least get a chance to chat," he said. "Then [they'll] leave and we'll close everything up and turn the heat back on."

He did, however, bring up a possibility that could spare him, and the rest of us, this discomfort: the widespread use of cheap, quick coronavirus tests. "Imagine those tests get better and they become ubiquitous-could you go and hang out with a friend if you both tested negative that morning, in a community that doesn't have large transmission? I would feel comfortable" doing that, he said. But "I probably wouldn't give them a hug and sit right next to them."

This winter, moving outdoor gatherings indoors could contribute to further increases in COVID-19 cases and deaths. "The winter could get a lot worse than even now," Noymer said. "There's plenty of room [in the population] for this thing to expand."

"We know that the biggest risk of spread for this virus is when meaningful numbers of people gather indoors for any extended period of time," Jha said. "Also, people are already feeling pandemic fatigue, and I think that'll only get worse." Due to the combination of indoor transmission risk and that increased desire to gather, he thinks "there almost surely will be a spike in cases" this winter.
Read: The coronavirus is never going away
Though data on the coronavirus's circulation during winter are scant, other respiratory viruses, such as influenza, tend to spread more readily in the winter than the summer. Noymer mentioned some possible explanations for this-that people spend more time indoors together, that the lower level of humidity suits the viruses better, that our mucous membranes get drier and more vulnerable to infection-and said he would be surprised if the coronavirus weren't aided in colder months by these or other forces.

Making matters worse, the pandemic will, if it isn't somehow neutralized, coincide with flu season, which usually starts in October and is at its worst December through February. Even though researchers don't yet know how severe this year's flu season will be, this overlap is worrying for three main reasons.

First, even in the absence of a pandemic, flu season can tax hospitals' beds and resources, Noymer said; having both the flu and COVID-19 spreading at once could further strain an already strained health-care system. Second, "COVID compromises the respiratory system and so does flu, so each of them makes the other one worse," Vlahov told me. (He says that everyone who's able should get the flu vaccine this year.) And third, because the two diseases have some symptoms in common, telling them apart can be difficult. That in turn can hinder efforts in hospitals to identify suspected COVID-19 cases, Vlahov said. It also could prompt worry and fear in people who don't know which disease they've come down with, notes Steven Taylor, the author of The Psychology of Pandemics.

Winter will be different from now in important, distressing ways, but in other ways it will be familiar. Looking ahead to the colder months, Vlahov thinks that they could resemble the homebound early stages of the pandemic, when many people who were able to "just stayed home and once a week went out for 20 minutes to get some grocery shopping done."
[ Read: Foodie culture as we know it is over ]
And many Americans are currently living in places where being outdoors for long periods of time already isn't feasible, because of the summer heat. A seasonal shift toward cooler indoor gatherings, Jha thought, might have contributed to rising case counts in some states that have had large outbreaks recently, such as Arizona and Texas. "It's not [primarily] about summer or winter," he explained. "It's about outdoors versus indoors ... Arizona in June is like Boston in December."

Also, Noymer noted that many Americans have no choice but to spend time in risky indoor conditions, no matter the season. "It's always winter inside a meatpacking plant," he said.

The U.S. may still be able to avert the most dismal predictions for winter. "I am more optimistic that November, December, January, February are not going to be some kind of apocalypse that looks like what life felt like in March or April," Jha said. "I think we can do better than that. But it will require policy intervention." Namely: widespread, affordable, and quick testing; strongly enforced masking mandates; and improved ventilation in classrooms and other indoor spaces.

[ Read: This isn't sustainable for working parents ]

But Jha can also envision a "nightmare scenario" playing out, with people cooped up indoors, schools closed, a still-weak testing regime, and a bad flu season. Americans could be living like that for months. "I think it is wholly avoidable, but 150,000 deaths later, a lot of this was avoidable," Jha said. "So I don't put it past our nation to botch the next phases of the response."

Jha is hoping that useful data from vaccine trials will be available by December. Learning then that a vaccine will arrive in the spring could fortify Americans for the winter, but if a vaccine turns out to still be a ways off, the season will be tougher to bear.

The shape of early 2021 could be apparent by the time the weather turns cold. Until then, savor the outdoors.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

Joe Pinsker is a staff writer at The Atlantic, where he covers families and relationships.

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Americans Are in for a Dangerous and Lonely Winter

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When socializing outside gets harder in much of the U.S., daily life will get more dismal and the virus might spread even further. Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

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How is it that six months into a respiratory pandemic, we are still doing so little to mitigate airborne transmission?

Millennium Images / Gallery Stock

I recently took a drive-through COVID-19 test at the University of North Carolina. Everything was well organized and efficient: I was swabbed for 15 uncomfortable seconds and sent home with two pages of instructions on what to do if I were to test positive, and what precautions people living with or tending to COVID-19 patients should take. The instructions included many detailed sections devoted to preventing transmission via surfaces, and also went into great detail about laundry, disinfectants, and the exact proportions of bleach solutions I should use to wipe surfaces, and how.
Read: The testing plan that could give us our lives back
My otherwise detailed instructions, however, included only a single sentence on "good ventilation"-a sentence with the potential to do some people more harm than good. I was advised to have "good air flow, such as from an air conditioner or an opened window, weather permitting." But in certain cases, air-conditioning isn't helpful. Jose-Luiz Jimenez, an air-quality professor at the University of Colorado, told me that some air conditioners can increase the chances of spreading infection in a household. Besides, "weather permitting" made it all seem insignificant, like an afterthought.

Recommended Reading

While waiting for my results, I checked the latest batch of announcements from companies trying to assure their customers that they were doing everything right. A major U.S. airline informed me how it was diligently sanitizing surfaces inside its planes and in terminals many times a day, without mentioning anything about the effectiveness of air circulation and filtering inside airplane cabins ( pretty good, actually). A local business that operates in a somewhat cramped indoor space sent me an email about how it was "keeping clean and staying healthy," illustrated by 10 bottles of hand sanitizer without a word on ventilation-whether it was opening windows, employing upgraded filters in its HVAC systems, or using portable HEPA filters. It seems baffling that despite mounting evidence of its importance, we are stuck practicing hygiene theater -constantly deep cleaning everything-while not noticing the air we breathe.

How is it that six months into a respiratory pandemic, we still have so little guidance about this all-important variable, the very air we breathe?

The coronavirus reproduces in our upper and lower respiratory tracts, and is emitted when we breathe, talk, sing, cough, or sneeze. Figuring out how a pathogen can travel, and how far, under what conditions, and infect others-transmission-is no small deal, because that information enables us to figure out how to effectively combat the virus. For COVID-19, perhaps the most important dispute centers specifically on what proportion of what size droplets are emitted from infected people, and how infectious those droplets are, and how they travel. That the debate over the virus's modes of transmission is far from over is not a surprise. It's a novel pathogen. The Columbia University virologist Angela Rasmussen told me that, historically, it took centuries to understand how pathogens such as the plague, smallpox, and yellow fever were transmitted and how they worked. Even with modern science, there are still debates about how influenza, a common annual foe, is transmitted.

In particular, the size of infectious particles really matters, because that determines how they travel-are they big enough to be quickly pulled down by gravity or are they small enough to float around? Since the beginning of the pandemic, the World Health Organization has considered the primary mode of COVID-19 transmission to be respiratory droplets. These droplets are defined as particles bigger than 5 to 10 microns in diameter, and WHO guidelines say that once they are sprayed out of someone's mouth, they travel ballistically and fall to the ground within close range of the infected person. For the WHO, that range is about three feet; for the Centers for Disease Control and Prevention, which also considers droplets to be the primary mode of transmission, it's six feet. The dominance of a ballistic-droplet mode of transmission in this pandemic would mean that we should focus mostly on staying out of droplets' range, especially to prevent them from falling on our unprotected mouth, nose, and eyes-hence the social-distancing guidelines. It also would mean that keeping that distance would be enough to stay safe from an infected person, on the other side of a room for example. (Of course, our hands can still potentially pick them up from surfaces and bring them to our face, hence the importance of hand-washing.)

There is a big dispute in the scientific community, however, about both the size and the behavior of these particles, and the resolution of that question would change many recommendations about staying safe. Many scientists believe that the virus is emitted from our mouths also in much smaller particles, which are infectious but also tiny enough that they can remain suspended in the air, float around, be pushed by air currents, and accumulate in enclosed spaces-because of their small size, they are not as subject to gravity's downward pull. Don Milton, a medical doctor and an environmental-health professor at the University of Maryland, compares larger droplets "to the spray from a Windex dispenser" and the smaller, airborne particles (aerosols) "to the mist from an ultrasonic humidifier." Clearly, it's enough to merely step back-distance-to avoid the former, but distancing alone would not be enough to avoid breathing in the latter.

The disagreement got heated enough that earlier this month, hundreds of scientists around the world signed a letter, pleading with the WHO to acknowledge these smaller particles as an extra mode of transmission and to update its guidelines accordingly. Some experts I spoke with told me that they had been trying to convince the WHO to take the possibility of airborne transmission since March, and that the open letter was borne out of frustration about lack of progress. Signatories who study aerosols-the smaller, floating particles-including professor Linsey Marr of Virginia Tech and Jimenez, told me that they don't disagree with the idea that transmission at close range represents the most risk, as per the WHO and CDC guidelines. But they disagree that the dominance of close-contact transmission implies that ballistic trajectories or larger respiratory droplets are the overwhelming mode of transmission. In their view, even some portion of that close-contact transmission is likely due to aerosols, and many experts told me that they think even particles bigger than the WHO's definition of respiratory droplets (larger than 5-10 microns in diameter) can float for a bit. In response, the WHO published a scientific brief on July 9 acknowledging the possibility of airborne transmission, but still concluding that COVID-19 is "primarily transmitted" between people through respiratory droplets and touching, and that the question needs "further study."
[ Read: What You Need to Know About the Coronavirus ]
Part of the difficulty with this discussion has been that the relevant experts, including infectious-disease specialists, epidemiologists, environmental and aerosol engineers, don't even agree on the terminology. The particles we emit from our mouths can be called droplets, microdroplets, droplet nuclei (particles that start out bigger but get smaller because of evaporation) or aerosols. There is no clear line between big and small particles and droplets and aerosols; it's a continuum with complex aerodynamics depending on the environment, and to make matters worse, the same word-like aerosol-sometimes means something different in each field. The terminological confusion led Milton to write a " Rosetta Stone " paper to try to clarify the terms across fields. For this article, I'll call the spray-borne particles that travel ballistically "droplets," and the ones that can float "aerosols" (regardless of what size the particles may be, as the key question is whether they can float and be pushed around by air-and that size cut-off remains disputed).

Plus, this debate has a long history: From the mid-19th century into the 20th century, infectious-disease specialists fought a long and hard-won battle against "miasma" theories of disease that posited that filth and noxious odors, instead of germs, were responsible for disease. In a seminal 1910 book, the public-health pioneer Charles Chapin distinguished "spray borne" diseases (WHO's droplets that maximally travel only a few feet) from "dust borne" ones-spread by aerosols, or airborne transmission. He concluded that most pathogens were either "spray-borne" or spread through contact, and worried that an over-reliance on "air-borne" theories would needlessly scare the public or cause them to neglect hand-washing. More than a century later, there are still echoes of those concerns.

There are also different kinds of "airborne" transmission-the term can sound scarier than reality and can become the basis for unnecessary scaremongering. For example, some airborne diseases, such as measles, will definitely spread to almost every corner of a house and can be expected to infect about 90 percent of susceptible people in the household. In the virus-panic movie Outbreak, when Dustin Hoffman's character exclaims, " It's airborne! " about Motaba, the film's fictional virus, he means that it will spread to every corner of the hospital through the vents. But not all airborne diseases are super-contagious (more on that in a bit), and, for the most part, the coronavirus does not behave like a super-infectious pathogen.
Read: Is the coronavirus airborne? Should we all wear masks?
In multiple studies, researchers have found that COVID-19's secondary attack rate, the proportion of susceptible people that one sick person will infect in a circumscribed setting, such as a household or dormitory, can be as low as 10 to 20 percent. In fact, many experts I spoke with remarked that COVID-19 was less contagious than many other pathogens, except when it seemed to occasionally go wild in super-spreader events, infecting large numbers of people at once, across distances much greater than the droplet range of three to six feet. Those who argue that COVID-19 can spread through aerosol routes point to the prevalence and conditions of these super-spreader events as one of the most important pieces of evidence for airborne transmission.

Saskia Popescu, an infectious-disease epidemiologist, emphasized to me that we should not call these "super-spreaders," referring only to the people, but "super-spreader events," because they seem to occur in very particular settings-an important clue. People don't emit an equal amount of aerosols during every activity: Singing emits more than talking, which emits more than breathing. And some people could be super-emitters of aerosols. But that's not all. The super-spreader-event triad seems to rely on three V's: venue, ventilation, and vocalization. Most super-spreader events occur at an indoor venue, especially a poorly ventilated one (meaning air is not being exchanged, diluted, or filtered), where lots of people are talking, chanting, or singing. Some examples of where super-spreader events have taken place are restaurants, bars, clubs, choir practices, weddings, funerals, cruise ships, nursing homes, prisons, and meatpacking plants.

Strikingly, in one database of more than 1,200 super-spreader events, just one incident is classified as outdoor transmission, where a single person was infected outdoors by their jogging partner, and only 39 are classified as outdoor/indoor events, which doesn't mean that being outdoors played a role, but it couldn't be ruled out. The rest were all indoor events, and many involved dozens or hundreds of people at once. Other research points to the same result: Super-spreader events occur overwhelmingly in indoor environments where there are a lot of people.

Benjamin Cowling, the head of epidemiology and biostatistics at the University of Hong Kong School of Public Health, points to a case at a restaurant in Guangzhou where a yet asymptomatic COVID-19 patient infected nine other people, many of whom were sitting at other tables but were in the direct line of the air conditioner, which was blowing air from one end of the restaurant to the other. Tables right next to the patient's but not downwind did not have a single infected person, and closed-circuit camera videos from the day show that the people at the infected tables didn't interact with the patient at all. It was the air. Cowling's colleagues analyzed the fluid dynamics of that outbreak, showing that the air conditioner blew the air in one direction, where it hit a wall, recirculated back, and was pushed out again, basically trapping the unlucky tables downwind, with the infected air going "round and round and round," as Cowling described it to me.
[ Read: Paging Dr. Hamblin: Can AC spread the coronavirus? ]
In another super-spreader event, at a choir practice of 61 people in Skagit County, Washington, a single patient caused 32 confirmed and 20 likely COVID-19 cases-almost everyone in the room. In another striking case, at a Korean call center, where people talk all day, 94 out of 216 people on one floor of the building were infected, with cases clustered on one side of the floor but some as far as 20 desks away from each other, with a few as far away as the opposite wall. Only three people on other floors were infected, despite the employees sharing a lobby and elevators, reinforcing that surfaces aren't efficient transmitters, but that shared air pockets can be, almost regardless of distance.

For these super-spreader events, Milton says you have to "really jump through hoops to argue that they were anything other than transmitted by air." But it's not only COVID-19's super-spreader events that are indoors. The rest of the pattern of spread of COVID-19 -when it is spreading slowly, in small numbers-is also overwhelmingly through indoor transmission. Milton told me that if those sprayed droplets were the primary means of transmission, we would expect to see more transmission outdoors, since the droplets are being ejected with some force and falling on people, but that doesn't seem to be the case. Even if sunlight, which can deactivate viruses, were dampening transmission outdoors, one would at least expect to see a lot more outdoor transmission than we are seeing now. Instead, epidemiologists are finding that this disease stalks us indoors.

There is also evidence from health-care settings. Hitoshi Oshitani, a virology professor at Tohoku University Graduate School of Medicine in Japan, told me that quarantine officers on the Diamond Princess cruise ship, who followed standard precautions against droplets and close contact, nonetheless got infected anyway. This was an important clue for Japanese scientists about the importance of aerosols. "Those were professionals," he said. For him, that meant that it was unlikely they slipped up, and more likely that the disease acted in ways they weren't prepared for. A recent (preprint) paper showed that health-care workers in the United Kingdom-where hospitals are older and ventilation measures are poorer- were getting sick at higher rates than those in the United States where many hospital buildings come with ventilation mitigation measures. And in a peer-reviewed paper just published in Nature, researchers reported finding viral RNA in more than half the air samples in a hospital, including outside patients' rooms and in the hallways. While it remains a question how infectious those particles may have been, Marr told me that it was significant that "100 percent of samples from the floor under the bed and all but one window ledge were positive for viral RNA, indicating that the virus was transported through the air and settled onto these surfaces."

However, to date, there is also no evidence of truly long-range transmission of COVID-19, or any pattern of spread like that of measles. Screaming "it's airborne!" can give the wrong impression to an already weary and panicked public, and that's one reason that some public-health specialists have been understandably wary of the term, sometimes even if they agreed aerosol transmission was possible. Cowling told me that it's better to call these "short-range aerosols," as that communicates the nature of the threat more accurately: Most of these particles are concentrated around the infected person, but, under the right circumstances, they can accumulate and get around.

All this has many practical consequences. As Marr, from Virginia Tech, says, if aerosols are crucial, we should focus as much on ventilation as we do on distancing, masks, and hand-washing, which every expert agrees are important. As the virologist Ryan McNamara of the University of North Carolina told me, all these protections stack on top of one another: The more tools we have to deploy against COVID-19, the better off we are. But, it's still important for the public to have the correct mental model of the reasoning behind all the mitigations, since even those agreed-upon protections don't all behave the same way under an aerosol regime.

For example, current WHO guidelines don't recommend masks indoors if a distance of one meter can be maintained. Similarly, the CDC makes scant reference to the distinction between indoor and outdoor transmission in its mask guidance, and recommends masks in public settings, " especially when other social distancing measures are difficult to maintain." However, an aerosol regime would suggest that distancing isn't as protective indoors as one would hope, especially since people eating and drinking tend to be talking while unmasked. (The CDC seems to recognize this when it recommends hosting gatherings outdoors, though it still officially stresses transmission through droplets).

Under an aerosol regime, we would have different rules for the indoors and the outdoors (especially since, in addition to the diluting power of air, sunlight quickly deactivates viruses.) We would mandate masks indoors regardless of distancing, but not necessarily outdoors. Marr told me that she wears her mask outdoors only if she's interacting with people, if she's in a crowd, or if she cannot maintain distance. Yet, in the United States, many locales are mandating masks indoors and outdoors under the same rules, forcing even the solitary person walking her dog to mask up. And there are places, such as Chicago, where beaches are closed because officials fear crowds, but indoor restaurants and gyms remain open with mild restrictions.

As another example, you may have seen the many televised indoor events where the audience members are sitting politely distanced and masked, listening to the speaker, who is the only unmasked person in the room. Jimenez, the aerosol expert, pointed out to me that this is completely backwards, because the person who needs to be masked the most is the speaker, not the listeners. If a single mask were available in the room, we'd put it on the speaker. This is especially important because cloth masks, while excellent at blocking droplets (especially before they evaporate and become smaller, thus more likely to be able to float), aren't as effective at keeping tinier aerosol particles out of the wearer's mouth and nose once they are floating around the room (though they do seem to help). We want to see the speaker's mouth, one might say, but that is a problem we can approach creatively-face shields that wrap around the head and seal around the neck, masks with transparent portions that can still filter, etc.-once we stop ignoring the problem. In fact, designing a high-filtration but transparent mask or face shield might be an important solution in classrooms as well, to help keep teachers safe.

Once we pay attention to airflow, many other risks look different. Dylan Morris, a doctoral candidate at Princeton and a co-author of the first paper to confirm that the virus could remain infectious in aerosolized form, under experimental conditions, showed me a clip of a group of people in a conga line, separated six feet apart by ropes. They were merrily dancing, everyone standing behind someone else, in their slipstream-exactly where you don't want to be, inhaling aerosol clouds from panting people. Similarly, Jimenez pointed out that, when a masked person is speaking, the least safe location might be beside them or behind them, where the aerosols can escape from the mask, though ordinarily, under a droplet regime, we would consider the risk to only be in front of them. The importance of aerosols may even help explain why the disease is now exploding in the southern United States, where people often go into air-conditioned spaces to avoid the sweltering heat.

Finally, all this would have implications for people around COVID-19 patients, especially in the community. In U.S. health-care settings, precautions against aerosols are usually already in place, partly because health-care workers undertake procedures-such as intubation-that generate aerosols even if a disease isn't very prone to creating them. (Most COVID-19 guidelines, including from the WHO and the CDC, from the beginning acknowledged aerosols to be a risk in health-care settings because of such procedures; the dispute has always been whether aerosol transmission occurs organically in everyday settings). However, in the community, accepting aerosol risks would mean that people around COVID-19 patients at home or anyone high-risk, such as the immunocompromised, should at least be provided with higher-grade masks such as N95s, which do a better job of keeping aerosols out.

There are two key mitigation strategies for countering poor ventilation and virus-laden aerosols indoors: We can dilute viral particles' presence by exchanging air in the room with air from outside (and thus lowering the dose, which matters for the possibility and the severity of infection) or we can remove viral particles from the air with filters.

Consider schools, perhaps the most fraught topic for millions. Classrooms are places of a lot of talking; children are not going to be perfect at social distancing; and the more people in a room, the more opportunities for aerosols to accumulate if the ventilation is poor. Most of these ventilation issues are addressable, sometimes by free or inexpensive methods, and sometimes by costly investments in infrastructure that should be a national priority.

Last week, I walked around the public elementary school in my neighborhood while thinking about what we could do if we took aerosol transmission more seriously. It's a single-story building, all the classrooms have windows, some have doors that open directly to the outside, and many have a cement patio right outside. Teaching could move outdoors, at least some of the time, the way it did during the 1918 pandemic. Moreover, even when indoors or during rainy days, opening the doors and windows would greatly improve air circulation inside, especially if classrooms had fans at the windows that pushed air out.
Read: Why can't we just have class outside?
When windows cannot be opened, classrooms could run portable HEPA filters, which are capable of trapping viruses this small, and which sell for as little as a few hundred dollars. Marr advises schools to measure airflow rates in each classroom, upgrade filters in the HVAC system to MERV 13 or higher ( these are air filter grades), and aspire to meet or exceed ASHRAE (the professional society that provides HVAC guidance and standards) standards. Jimenez told me that many building-wide air-conditioning systems have a setting for how much air they take in from outside, and that it is usually minimized to be energy-efficient. During a pandemic, saving lives is more important than saving energy, so schools could, when the setting exists, crank it up to dilute the air (Jimenez told me that Shelly Miller, a fellow professor at the University of Colorado specializing in indoor air quality, persuaded the university to do just that.)

Jimenez also wondered why the National Guard hadn't been deployed to set up tent schools (not sealed, but letting air in like an outdoor wedding canopy) around the country, and why the U.S. hadn't set up the mass production of HEPA filters for every classroom and essential indoor space. Instead, one air-quality expert reported, teachers who wanted to buy portable HEPA filters were being told that they weren't allowed to, because the CDC wasn't recommending them. It is still difficult to get Clorox wipes in my supermarket, but I went online to check, and there is no shortage of portable HEPA filters. There is no run on them.

Some countries have already bucked the trend of ignoring short-range aerosols. Oshitani told me that in Japan, researchers took short-range aerosol transmission seriously from the start, and focused on the few transmission events that spread the disease to large numbers of people at once. Cowling, of Hong Kong University, told me the same thing: He considers short-range aerosols and super-spreader events to be key to the spread of COVID-19. Japan was expected to fail by many, as it implemented an unconventional response, bucking WHO guidelines, eschewing widespread testing, and forcing few formal lockdowns. However, Japan masked up early, focused on super-spreader events (a strategy it calls " cluster busting"), and, crucially, trained its public to focus on avoiding the three C's-closed spaces, crowded places, and close conversations. In other words, exactly the places where airborne transmission and aerosols could pose a risk. The Japanese were advised not to talk on the subway, where windows were kept open. Oshitani said they also developed guidelines that included the importance of ventilation in many different settings, such as bars, restaurants, and gyms. Six months later, despite having some of the earliest outbreaks, ultradense cities, and one of the oldest populations in the world, Japan has had about 1,000 COVID-19 deaths total-which is how many the United States often has in a single day. Hong Kong, a similarly dense and subway-dependent city, has had only 24 deaths.

To be clear, the science concerning aerosols isn't settled, which is acknowledged by the signatories of the letter to the WHO urging recognition and mitigation of possible aerosol risks. Rasmussen, the Columbia virologist, could easily rattle off many things she'd like to know about airborne transmission: how much infectious virus is in a given droplet, if some people shed a lot more of the virus than others, or, at what point in their infection, if the virus is more concentrated in the droplet nuclei and what constitutes an infectious dose. But facing a pandemic, we have to act with imperfect information. The letter writers stress that "we must address every potentially important pathway to slow the spread of COVID-19," even if evidence is incomplete, especially since some of the measures are as simple as opening a window and moving outdoors. This is especially crucial because mitigations stack: The more we have available, the more effective they become.

In this period when we don't have all the answers, much is at stake. My COVID-19 test was negative, so I didn't need to worry about that, but I wonder about the alternate world, where we take aerosols seriously, had I tested positive, I would have been sent home with firm instructions on opening windows, a loaner HEPA filter, N95 masks for my housemates, and strong warnings not to assume that staying six feet away from me was enough.

Marr told me that she "sheepishly" switched her elementary- and middle-school-age children to a private school because she was able to make a case with the school to take "good ventilation" seriously, in addition to wearing masks and social distancing. Not every school will have such resources, but maybe providing those resources is exactly what we should aspire to for all schools. If the signatories of the letter to the WHO are correct, then adding ventilation to our mitigation stack is exactly what we should focus on, doing everything necessary ranging from the more expensive upgrades to our air-quality infrastructure to opening the windows that are right within our reach.

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columbia university virologist angela rasmussen

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tohoku university graduate school of medicine

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How is it that six months into a respiratory pandemic, we are still doing so little to mitigate airborne transmission? I recently took a drive-through COVID-19 test at the University of North Carolina.

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When it comes to the daunting question of reopening schools, America's educators deserve a plan, not a trap.

I hate to break it to you, but I was a terrible student.

Each day, I desperately waited for the final bell to ring so that I could be released from the confines of my stuffy, windowless classroom and run home to my guitar. It was no fault of the Fairfax County Public Schools system, mind you; it did the best it could. I was just stubbornly disengaged, impeded by a raging case of ADD and an insatiable desire to play music. Far from being a model student, I tried my best to maintain focus, but eventually left school halfway through 11th grade to follow my dreams of becoming a professional touring musician (not advised). I left behind countless missed opportunities. To this day, I'm haunted by a recurring dream that I'm back in those crowded hallways, now struggling to graduate as a 51-year-old man, and anxiously wake in a pool of my own sweat. You can take the boy out of school, but you can't take school out of the boy! So, with me being a high-school dropout, you would imagine that the current debate surrounding the reopening of schools wouldn't register so much as a blip on my rock-and-roll radar, right? Wrong.

My mother was a public-school teacher.
Read: Colleges are getting ready to blame their students
As a single mother of two, she tirelessly devoted her life to the service of others, both at home and at work. From rising before dawn to ensure that my sister and I were bathed, dressed, and fed in time to catch the bus to grading papers well into the night, long after her dinner had gone cold, she rarely had a moment to herself. All this while working multiple jobs to supplement her meager $35,000 annual salary. Bloomingdale's, Servpro, SAT prep, GED prep-she even once coached soccer for a $400 stipend, funding our first family trip to New York City, where we stayed at the St. Regis Hotel and ordered drinks at its famous King Cole Bar so that we could fill up on the free hors d'oeuvres we otherwise could not afford. Unsurprisingly, her devoted parenting mirrored her technique as a teacher. Never one to just point at a blackboard and recite lessons for kids to mindlessly memorize, she was an engaging educator, invested in the well-being of each and every student who sat in her class. And at an average of 32 students a class, that was no small feat. She was one of those teachers who became a mentor to many, and her students remembered her long after they had graduated, often bumping into her at the grocery store and erupting into a full recitation of Shakespeare's Julius Caesar, like a flash mob in the produce aisle. I can't tell you how many of her former students I've met over the years who offer anecdotes from my mother's classroom. Every kid should be so lucky to have that favorite teacher, the one who changes your life for the better. She helped generations of children learn how to learn, and, like most other teachers, exhibited a selfless concern for others. Though I was never her student, she will forever be my favorite teacher.
Read: How Trump closed down the schools
It takes a certain kind of person to devote their life to this difficult and often-thankless job. I know because I was raised in a community of them. I have mowed their lawns, painted their apartments, even babysat their children, and I'm convinced that they are as essential as any other essential workers. Some even raise rock stars! Tom Morello of Rage Against the Machine, Adam Levine, Josh Groban, and Haim are all children of school workers (with hopefully more academically rewarding results than mine). Over the years, I have come to notice that teachers share a special bond, because there aren't too many people who truly understand their unique challenges-challenges that go far beyond just pen and paper. Today, those challenges could mean life or death for some.

When it comes to the daunting-and ever more politicized-question of reopening schools amid the coronavirus pandemic, the worry for our children's well-being is paramount. Yet teachers are also confronted with a whole new set of dilemmas that most people would not consider. "There's so much more to be addressed than just opening the doors and sending them back home," my mother tells me over the phone. Now 82 and retired, she runs down a list of concerns based on her 35 years of experience: "masks and distancing, temperature checks, crowded busing, crowded hallways, sports, air-conditioning systems, lunchrooms, public restrooms, janitorial staff." Most schools already struggle from a lack of resources; how could they possibly afford the mountain of safety measures that will need to be in place? And although the average age of a schoolteacher in the United States is in the early 40s, putting them in a lower-risk group, many career teachers, administrators, cafeteria workers, nurses, and janitors are older and at higher risk. Every school's working faculty is a considerable percentage of its population, and should be safeguarded appropriately. I can only imagine if my mother were now forced to return to a stuffy, windowless classroom. What would we learn from that lesson? When I ask what she would do, my mother replies, "Remote learning for the time being."
Read: Reopening schools was an afterthought
Remote learning comes with more than a few of its own complications, especially for working-class and single parents who are dealing with the logistical problem of balancing jobs with children at home. Uneven availability of teaching materials and online access, technical snafus, and a lack of socialization all make for a less-than-ideal learning experience. But most important, remote setups overseen by caretakers, with a teacher on the other end doing their best to educate distracted kids who prefer screens used for games, not math, make it perfectly clear that not everyone with a laptop and a dry-erase board is cut out to be a teacher. That specialized skill is the X factor. I know this because I have three children of my own, and my remote classroom was more Welcome Back, Kotter than Dead Poets Society. Like I tell my children, "You don't really want daddy helping, unless you want to get an F!" Remote learning is an inconvenient and hopefully temporary solution. But as much as Donald Trump's conductor-less orchestra would love to see the country prematurely open schools in the name of rosy optics (ask a science teacher what they think about White House Press Secretary Kayleigh McEnany's comment that "science should not stand in the way"), it would be foolish to do so at the expense of our children, teachers, and schools.
Read: Why schools can't reopen in the fall
Every teacher has a "plan." Don't they deserve one too? My mother had to come up with three separate lesson plans every single day (public speaking, AP English, and English 10), because that's what teachers do: They provide you with the necessary tools to survive. Who is providing them with a set of their own? America's teachers are caught in a trap, set by indecisive and conflicting sectors of failed leadership that have never been in their position and can't possibly relate to the unique challenges they face. I wouldn't trust the U.S. secretary of percussion to tell me how to play "Smells Like Teen Spirit" if they had never sat behind a drum set, so why should any teacher trust Secretary of Education Betsy DeVos to tell them how to teach, without her ever having sat at the head of a class? (Maybe she should switch to the drums.) Until you have spent countless days in a classroom devoting your time and energy to becoming that lifelong mentor to generations of otherwise disengaged students, you must listen to those who have. Teachers want to teach, not die, and we should support and protect them like the national treasures that they are. For without them, where would we be?

May we show these tireless altruists a little altruism in return. I would for my favorite teacher. Wouldn't you?

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When it comes to the daunting question of reopening schools, America's educators deserve a plan, not a trap.

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Coronavirus testing at a site in Los Angeles last week. The pathogen has infected at least 4.3 million Americans, killing almost 150,000. Credit... Jenna Schoenefeld for The New York Times

There's not just one coronavirus outbreak in the United States. Now there are many, each requiring its own mix of solutions.

Coronavirus testing at a site in Los Angeles last week. The pathogen has infected at least 4.3 million Americans, killing almost 150,000. Credit... Jenna Schoenefeld for The New York Times

Once again, the coronavirus is ascendant. As infections mount across the country, it is dawning on Americans that the epidemic is now unstoppable, and that no corner of the nation will be left untouched.

As of Tuesday, the pathogen had infected at least 4.3 million Americans, killing almost 150,000. Many experts fear the virus could kill 200,000 or even 300,000 by year's end. Even President Trump has donned a mask, after resisting for months, and has canceled the Republican National Convention celebrations in Florida.

Each state, each city has its own crisis driven by its own risk factors: vacation crowds in one, bars reopened too soon in another, a revolt against masks in a third.

"We are in a worse place than we were in March," when the virus coursed through New York, said Dr. Leana S. Wen, a former Baltimore health commissioner. "Back then we had one epicenter. Now we have lots."

To assess where the country is heading now, The New York Times interviewed 20 public health experts - not just clinicians and epidemiologists, but also historians and sociologists, because the spread of the virus is now influenced as much by human behavior as it is by the pathogen itself.

Not only are American cities in the South and West facing deadly outbreaks like those that struck Northeastern cities in the spring, but rural areas are being hurt, too. In every region, people of color will continue to suffer disproportionately, experts said.

While there may be no appetite for a national lockdown, local restrictions must be tightened when required, the researchers said, and governors and mayors must have identical goals. Testing must become more targeted.

In most states, contact tracing is now moot - there are simply too many cases to track. And while progress has been made on vaccines, none is expected to arrive this winter in time to stave off what many fear will be a new wave of deaths.

Overall, the scientists conveyed a pervasive sense of sadness and exhaustion. Where once there was defiance, and then a growing sense of dread, now there seems to be sorrow and frustration, a feeling that so many funerals never had to happen and that nothing is going well. The United States is a wounded giant, while much of Europe, which was hit first, is recovering and reopening - although not to us.

"We're all incredibly depressed and in shock at how out of control the virus is in the U.S.," said Dr. Michele Barry, the director of the Center for Innovation in Global Health at Stanford University.

With so much wealth and medical talent, they asked, how could we have done so poorly? How did we fare not just worse than autocratic China and isolated New Zealand, but also worse than tiny, much poorer nations like Vietnam and Rwanda?

"National hubris and belief in American exceptionalism have served us badly," said Martha L. Lincoln, a medical anthropologist and historian at San Francisco State University. "We were not prepared to see the risk of failure."

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The infection may start in the lungs, but it is very different from influenza, a respiratory virus. In severely ill patients, the coronavirus may attach to receptors inside the veins and arteries, and move on to attack the kidneys, the heart, the gut and even the brain, choking off these organs with hundreds of tiny blood clots.

Most of the virus's victims are elderly, but it has not spared young adults, especially those with obesity, high blood pressure or diabetes. Adults aged 18 to 49 now account for more hospitalized cases than people aged 50 to 64 or those 65 and older.

Children are usually not harmed by the virus, although clinicians were dismayed to discover a few who were struck by a rare but dangerous inflammatory version. Young children appear to transmit the virus less often than teenagers, which may affect how schools can be opened.

Among adults, a very different picture has emerged. Growing evidence suggests that perhaps 10 percent of the infected account for 80 percent of new transmissions. Unpredictable superspreading events in nursing homes, meatpacking plants, churches, prisons and bars are major drivers of the epidemic.

Thus far, none of the medicines for which hopes were once high - repurposed malaria drugs, AIDS drugs and antivirals - have proved to be rapid cures. One antiviral, remdesivir, has been shown to shorten hospital stays, while a common steroid, dexamethasone, has helped save some severely ill patients.

One or even several vaccines may be available by year's end, which would be a spectacular achievement. But by then the virus may have in its grip virtually every village and city on the globe.

Some experts, like Michael T. Osterholm, the director of the University of Minnesota's Center for Infectious Disease Research and Policy, argue that only a nationwide lockdown can completely contain the virus now. Other researchers think that is politically impossible, but emphasize that localities must be free to act quickly and enforce strong measures with support from their state capitols.

Danielle Allen, the director of Harvard University's Edmond J. Safra Center for Ethics, which has issued pandemic response plans, said that finding less than one case per 100,000 people means a community should continue testing, contact tracing and isolating cases - with financial support for those who need it.

Up to 25 cases per 100,000 requires greater restrictions, like closing bars and limiting gatherings. Above that number, authorities should issue stay-at-home orders, she said.

Testing must be focused, not just offered at convenient parking lots, experts said, and it should be most intense in institutions like nursing homes, prisons, factories or other places at risk of superspreading events.

Testing must be free in places where people are poor or uninsured, such as public housing projects, Native American reservations and churches and grocery stores in impoverished neighborhoods.

None of this will be possible unless the nation's capacity for testing, a continuing disaster, is greatly expanded. By the end of summer, the administration hopes to start using "pooling," in which tests are combined in batches to speed up the process.

But the method only works in communities with lower infection rates, where large numbers of pooled tests turn up relatively few positive results. It fails where the virus has spread everywhere, because too many batches turn up positive results that require retesting.

At the moment, the United States tests roughly 800,000 people per day, about 38 percent of the number some experts think is needed.

Above all, researchers said, mask use should be universal indoors - including airplanes, subway cars and every other enclosed space - and outdoors anywhere people are less than six feet apart.

Dr. Emily Landon, an infection control specialist at the University of Chicago Pritzker School of Medicine, said it was "sad that something as simple as a mask got politicized."

"It's not a statement, it's a piece of clothing," she added. "You get used to it the way you got used to wearing pants."

Arguments that masks infringe on personal rights must be countered both by legal orders and by persuasion. "We need more credible messengers endorsing masks," Dr. Wen said - just before the president himself became a messenger.

"They could include C.E.O.s or celebrities or religious leaders. Different people are influencers to different demographics."

Although this feels like a new debate, it is actually an old one. Masks were common in some Western cities during the 1918 flu pandemic and mandatory in San Francisco. There was even a jingle: "Obey the laws, wear the gauze. Protect your jaws from septic paws."

"A libertarian movement, the Anti-Mask League, emerged," Dr. Lincoln of San Francisco State said. "There were fistfights with police officers over it." Ultimately, city officials "waffled" and compliance faded.

"I wonder what this issue would be like today," she mused, "if that hadn't happened."

Images of Americans disregarding social distancing requirements have become a daily news staple. But the pictures are deceptive: Americans are more accepting of social distancing than the media sometimes portrays, said Beth Redbird, a Northwestern University sociologist who since March has conducted regular surveys of 8,000 adults about the impact of the virus.

"About 70 percent of Americans report using all forms of it," she said. "And when we give them adjective choices, they describe people who won't distance as mean, selfish or unintelligent, not as generous, open-minded or patriotic."

The key predictor, she said in early July, was whether or not the poll respondent trusted Mr. Trump. Those who trusted him were less likely to practice social distancing. That was true of Republicans and independents, "and there's no such thing as a Democrat who trusts Donald Trump," she added.

Whether or not people support coercive measures like stay-at-home orders or bar closures depended on how scared the respondent was.

"When rising case numbers make people more afraid, they have more taste for liberty-constraining actions," Dr. Redbird said. And no economic recovery will occur, she added, "until people aren't afraid. If they are, they won't go out and spend money even if they're allowed to."

As of Tuesday, new infections were still rising in 28 states, according to a database maintained by The Times.

Weeks ago, experts like Dr. Anthony S. Fauci, the director of the National Institute for Allergy and Infectious Diseases, were advising states where the virus was surging to pull back from reopening by closing down bars, forbidding large gatherings and requiring mask usage.

Many of those states are finally taking that advice, but it is not yet clear whether this national change of heart has happened in time to stop the newest wave of deaths from ultimately exceeding the 2,750-a-day peak of mid-April. Through Tuesday, the seven-day average was 1,078 virus deaths nationwide.

Deaths may surge even higher, experts warned, when cold weather, rain and snow force Americans to meet indoors, eat indoors and crowd into public transit.

Oddly, states that are now hard-hit might become safer, some experts suggested. In the South and Southwest, summers are so hot that diners seek air-conditioning indoors, but eating outdoors in December can be pleasant.

Several studies have confirmed transmission in air-conditioned rooms. In one well-known case cluster in a restaurant in Guangzhou, China, researchers concluded that air-conditioners blew around a viral cloud, infecting patrons as far as 10 feet from a sick diner.

Rural areas face another risk. Almost 80 percent of the country's counties lack even one infectious disease specialist, according to a study led by Dr. Rochelle Walensky, the chief of infectious diseases at Massachusetts General Hospital in Boston.

At the moment, the crisis is most acute in Southern and Southwestern states. But websites that track transmission rates show that hot spots can turn up anywhere. For three weeks, for example, Alaska's small outbreak has been one of the country's fastest-spreading, while transmission in Texas and Arizona has dramatically slowed.

Deaths now may rise more slowly than they did in spring, because hospitalized patients are, on average, younger this time. But overwhelmed hospitals can lead to excess deaths from many causes all over a community, as ambulances are delayed and people having health crises avoid hospitals out of fear.

The experts were divided as to what role influenza will play in the fall. A harsh flu season could flood hospitals with pneumonia patients needing ventilators. But some said the flu season could be mild or almost nonexistent this year.

Normally, the flu virus migrates from the Northern Hemisphere to the Southern Hemisphere in the spring - presumably in air travelers - and then returns in the fall, with new mutations that may make it a poor match for the annual vaccine.

But this year, the national lockdown abruptly ended flu transmission in late April, according to weekly Fluview reports from the Centers for Disease Control and Prevention. International air travel has been sharply curtailed, and there has been almost no flu activity in the whole southern hemisphere this year.

Assuming there is still little air travel to the United States this fall, there may be little "reseeding" of the flu virus here. But in case that prediction turns out be wrong, all the researchers advised getting flu shots anyway.

"There's no reason to be caught unprepared for two respiratory viruses," said Tara C. Smith, an epidemiologist at Kent State University's School of Public Health.

Experts familiar with vaccine and drug manufacturing were disappointed that, thus far, only dexamethasone and remdesivir have proved to be effective treatments, and then only partially.

Most felt that monoclonal antibodies - cloned human proteins that can be grown in cell culture - represented the best hope until vaccines arrive. Regeneron, Eli Lilly and other drugmakers are working on candidates.

"They're promising both for treatment and for prophylaxis, and there are companies with track records and manufacturing platforms," said Dr. Luciana Borio, a former director of medical and biodefense preparedness at the National Security Council. "But manufacturing capacity is limited."

According to a database compiled by The Times, researchers worldwide are developing more than 165 vaccine candidates, and 27 are in human trials.

New announcements are pouring in, and the pressure to hurry is intense: The Trump administration just awarded nearly $2 billion to a Pfizer-led consortium that promised 100 million doses by December, assuming trials succeed.

Because the virus is still spreading rapidly, most experts said "challenge trials," in which a small number of volunteers are vaccinated and then deliberately infected, would probably not be needed.

Absent a known cure, "challenges" can be ethically fraught, and some doctors oppose doing them for this virus. "They don't tell you anything about safety," Dr. Borio said.

And when a virus is circulating unchecked, a typical placebo-controlled trial with up to 30,000 participants can be done efficiently, she added. Moderna and Pfizer have already begun such trials.

The Food and Drug Administration has said a vaccine will pass muster even if it is only 50 percent effective. Experts said they could accept that, at least initially, because the first vaccine approved could save lives while testing continued on better alternatives.

"A vaccine doesn't have to work perfectly to be useful," Dr. Walensky said. "Even with measles vaccine, you can sometimes still get measles - but it's mild, and you aren't infectious."

"We don't know if a vaccine will work in older folks. We don't know exactly what level of herd immunity we'll need to stop the epidemic. But anything safe and fairly effective should help."

Still, haste is risky, experts warned, especially when opponents of vaccines are spreading fear. If a vaccine is rushed to market without thorough safety testing and recipients are hurt by it, all vaccines could be set back for years.

No matter what state the virus reaches, one risk remains constant. Even in states with few Black and Hispanic residents, they are usually hit hardest, experts said.

People of color are more likely to have jobs that require physical presence and sometimes close contact, such as construction work, store clerking and nursing. They are more likely to rely on public transit and to live in neighborhoods where grocery stores are scarce and crowded.

They are more likely to live in crowded housing and multigenerational homes, some with only one bathroom, making safe home isolation impossible when sickness strikes. They have higher rates of obesity, high blood pressure, diabetes and asthma.

Federal data gathered through May 28 shows that Black and Hispanic Americans were three times as likely to get infected as their white neighbors, and twice as likely to die, even if they lived in remote rural counties with few Black or Hispanic residents.

"By the time that minority patient sets foot in a hospital, he is already on an unequal footing," said Elaine Hernandez, a sociologist at Indiana University.

The differences persist even though Black and Hispanic adults drastically altered their behavior. One study found that through the beginning of May, the average Black American practiced more social distancing than the average white American.

Officials in Chicago, Baltimore and other communities faced another threat: rumors flying about social media that Black people were somehow immune.

The top factor making people adopt self-protective behavior is personally knowing someone who fell ill, said Dr. Redbird. By the end of spring, Black and Hispanic Americans were 50 percent more likely than white Americans to know someone who had been ill, her surveys found.

Dr. Hernandez, whose parents live in Arizona, said their neighbors who had not been scared in June had since changed their attitudes.

Her father, a physician, had set an example. Early on, he wore a mask with a silly mustache when he and his wife took walks, and they would decline friends' invitations, saying, "No, we're staying in our bubble."

Now, she said, their neighbors are wearing masks, "and people are telling my father, 'You were right,'" Dr. Hernandez said.

There was no widespread agreement among experts about what is likely to happen in the years after the pandemic. Some scientists expected a quick economic recovery; others thought the damage could persist for years.

Working at home will become more common, some predicted, while crowded, open-plan offices may be changed. The just-in-time supply chains on which many businesses depend will need fixing because the processes failed to deliver adequate protective gear, ventilators and test materials.

A disease-modeling system like that used by the National Weather Service to predict storms is needed, said Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. Right now, the country has surveillance for seasonal flu but no national map tracking all disease outbreaks. As Dr. Thomas R. Frieden, a former C.D.C. director, recently pointed out, states are not even required to track the same data.

Several experts said they assumed that millions of Americans who have been left without health insurance or forced to line up at food banks would vote for politicians favoring universal health care, paid sick leave, greater income equality and other changes.

But given the country's deep political divisions, no researcher was certain what the outcome of the coming election would be.

Dr. Redbird said her polling of Americans showed "little faith in institutions across the board - we're not seeing an increase in trust in science or an appetite for universal health care or workers equity."

The Trump administration did little to earn trust. More than six months into the worst health crisis in a century, Mr. Trump only last week urged Americans to wear masks and canceled the Republican convention in Florida, the kind of high-risk indoor event that states have been banning since mid-March.

"It will probably, unfortunately, get worse before it gets better," Mr. Trump said at the first of the resurrected coronavirus task force briefings earlier this month, which included no scientists or health officials. The briefings were discontinued in April amid his rosy predications that the epidemic would soon be over.

Mr. Trump has ignored, contradicted or disparaged his scientific advisers, repeatedly saying that the virus simply would go away, touting unproven drugs like hydroxychloroquine even after they were shown to be ineffective and sometimes dangerous, and suggesting that disinfectants or lethal ultraviolet light might be used inside the body.

Millions of Americans have lost their jobs and their health insurance, and are in danger of losing their homes, even as they find themselves in the path of a lethal disease. The Trump presidency "is the symptom of the denigration of science and the gutting of the public contract about what we owe each other as citizens," said Dr. Joia S. Mukherjee, the chief medical officer of Partners in Health in Boston.

One lesson that will surely be learned is that the country needs to be better prepared for microbial assaults, said Dr. Julie Gerberding, a former director of the C.D.C.

"This is not a once-in-a-century event. It's a harbinger of things to come."

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A Viral Epidemic Splintering Into Deadly Pieces

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There's not just one coronavirus outbreak in the United States. Now there are many, each requiring its own mix of solutions. Coronavirus testing at a site in Los Angeles last week. The pathogen has infected at least 4.3 million Americans, killing almost 150,000. Credit...

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In a year without a Great Plague, we'd be in peak wedding season right about now. Unfortunately, passed appetizers and champagne toasts have largely been relegated to the same nostalgic category as spin classes and shared office doughnuts.

Per the most recent set of guidelines issued by the L.A. County Department of Public Health, "individual and family gatherings or parties of any size aren't allowed." But, whether advisable or not, some people are beginning to plan parties and weddings again. Which leaves potential guests wondering: How do I say no? Can I say no? What if I already RSVP'd? How do I phrase it without sounding judgmental?

If you don't care at all about the person who's asking you, saying no is easy: Say "no." But assuming this is someone with whom you'd like to continue a relationship once the pandemic is over, it can be a little trickier. We turned to some experts for guidance.

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How to say no politely
Of course you are allowed to say no. You are allowed to say that at all times, to all invitations, under all circumstances. But especially right now, in the middle of a pandemic.

So it's less about whether you can say it and more about how, experts say. Tone matters. Put a smile on your face when you make the call and keep it simple: "Thank you for the invitation, I'm so sorry but I can't make it."

You don't need to explain why or start adding qualifiers or caveats. That's where you run the risk of veering into judgmental territory.

"Your sole purpose is to accept or decline an invitation. We're taking on too much with the feeling that we need to go into detail and explain," said Elaine Swann, a lifestyle and etiquette expert and the founder of the Swann School of Protocol in Carlsbad, Calif. "Don't go into detail and say, 'I'm not attending anything.' I think that's where you open yourself up for conversation and scrutiny and debate."
But what if I've already RSVP'd?
Even if it's something you've already RSVP'd to, like a wedding, you can still go back to the host and decline. It isn't rude to change your mind about going to an event where your attendance could be risking your life. What would be rude would be to wait until the last minute to do so: As soon as you know you won't be going, get in touch with the hosts and tell them. Give them time to adjust their seating charts and catering orders.

When conveying the message, again, graciousness and simplicity are key: "I wanted to update you about my RSVP for your wedding. Thank you so much for inviting me, but unfortunately I won't be able to make it."
You can still send a gift
Just because you can't go to an event doesn't mean you can't be appreciative toward the host. If it's a milestone birthday or a wedding, send a card and a gift. If it's a more casual get-together, have flowers delivered or send the hosts some money ahead of time with a note: "So sorry I can't be there. Dessert's on me!" Reach out to the hosts again the day after the party and tell them you wish you could have attended and you can't wait to see the photos.

You can also offer alternatives to getting together on that day: Plan a time to sing "Happy Birthday" on video chat the day before or offer to drop off dinner at their house later that week.

If you do decline an event, be consistent. It would be extremely poor manners to post photos of yourself a week later throwing a barbecue or having a pool party.
Inquiring about social distancing
Everyone's personal risk assessment is different right now. Maybe you'd feel comfortable going to a backyard barbecue, but only if everyone will be wearing masks and staying six feet apart. In this uncharted etiquette territory, is it OK to ask the hosts if they'll be doing double duty as social distancing enforcer?

"Generally, no," said Jules Hirst, an etiquette coach based in Los Angeles and the co-author of the book "The Power of Civility." It depends on your relationship with the host, she said. If it's a family member or someone you're close to, it's more acceptable to inquire. You could also use their past behavior for reference: If they've posted a bunch of photos of themselves in crowded public areas or at other parties with no mask on, it's reasonable to assume they won't be strict about things at their own house.

If you do ask, phrasing it as a yes-or-no question will probably yield more useful information than broadly asking about social distancing, since not everyone has quite the same understanding of what "good social distancing" looks like. Will you be asking people to wear masks? Will families be seated at least six feet away from each other?
Get comfortable with being uncomfortable
To be clear: These are awkward questions. It's kind of like asking another parent if they have a gun in their home before sending your child over to play. No matter what the answer is, there's a chance you'll have offended the person by asking at all. But the stakes are similarly high.

"We are dealing with a worldwide pandemic and this is what our current state of affairs looks like. It's really important for us to be mindful in that regard and be bold and empowered enough to ask those hard questions," Swann said. "Right now you're doing your part for the health of yourself and your loved ones."
When social distancing gets overly social
You've been reassured that masks will be on and distance will be maintained. But after a couple of hours (and a couple of cocktails), you notice social distancing and masks starting to slip. That is your cue to exit.

Don't ascend your soapbox and deliver a speech about why you're leaving, as satisfying as it might feel in the moment. And don't go tattling to the host.

If you've reached the point when other guests' behavior is making you uncomfortable, "it's probably best to go over and thank the host for inviting you and say you had a wonderful time but you have to get going," said Jessica Marventano, co-founder of the etiquette website Marvelously Well-Mannered. "I wouldn't say to someone in the middle of the party that they're having, 'Oh, you know the people in the corner are taking off their masks,' because then you're saying the host isn't doing their job and you're taking away their joy of hosting the party."

If you know ahead of time that certain guests are probably going to ignore social distancing protocols, no matter how much the host says they'll be enforcing things, it's better to not go at all. In other words: If Uncle Kevin who posts daily anti-mask rants on Facebook is going to be there, skip it, even if your cousin swears she'll make everyone wear the cute matching family reunion masks she ordered.
Defusing difficult conversations
In most cases, when you're saying "thanks, but no thanks" or making a hasty departure, the host will understand. But not always. How do you deal with friends or family members who think you're an elitist or a sheep or a fool for taking basic health precautions? How do you change their mind and make them realize how serious this is?

Basically, you don't. "No" is a complete sentence; "Thank you, but no" is as well. It isn't your responsibility to convince everyone in your life that you're right and they're wrong.

"Our goal is not to try to correct anyone or chastise them or even educate them," Swann said. "We should not take on the task of trying to correct or fix other people. The only thing we can do is correct ourselves."
Some minds can't be changed
Even knowing someone firsthand who's been affected isn't always enough to persuade people to take it seriously. Hirst said her cousin died of COVID-19 after attending a gathering. Later, at her niece's drive-through birthday party, she was shocked to see other guests coming out of the backyard.

"I said to my sister, 'How could you? Tommy went to a barbecue and died two weeks later. How can you do this? We know somebody; this is personal now.'"

Hirst compared the social distancing issue to politics: At a certain point, you have to agree to disagree and just change the subject. At this point, everyone is aware of the coronavirus, and everyone has formed their own opinion about it. You're unlikely to change someone's mind with articles and graphics and well-reasoned arguments, so don't bother.

"You just can't change people's minds. You can't. That's it."
Politeness still matters
And on the other side of the debate, some people reading this might be wondering why we should care about etiquette at all in these situations. Doesn't a pandemic take precedence over politeness? Yes - but that doesn't mean manners are now irrelevant.

"Whatever the CDC and government officials are telling us, these are guidelines to keep us alive and keep us healthy," Hirst said. "Manners are a guideline so you still have friends when this is over."

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Your friend is throwing a party during a pandemic. How do you say no?

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In a year without a Great Plague, we'd be in peak wedding season right about now. Unfortunately, passed appetizers and champagne toasts have largely been relegated to the same nostalgic category as spin classes and shared office doughnuts. Per the most recent set of guidelines issued by the L.A.

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As scientists study the burden of COVID-19 around the globe, it's pretty clear that despite some cases of serious illness, kids tend to get infected with the coronavirus less often and have milder symptoms compared to adults.

"It seems consistently, children do have lower rates of infection than adults," says Dr. Alison Tribble, a pediatric infectious disease specialist at C.S. Mott Children's Hospital at the University of Michigan.

What's much less understood is the extent to which kids can spread the illness among themselves - or to the adults with whom they come in close contact.

A lack of testing early in the pandemic has been part of the problem, says Dr. Judy Guzman-Cottrill, an infectious disease pediatrician at Oregon Health and Science University. "We need more robust epidemiologic studies to evaluate how children are part of the transmission chain," she says.

Given the uncertainty, the decisions on how to safely reopen schools are tricky.

"Kids don't seem to be super spreaders," says Dr. Aaron Carroll, a pediatrician at Indiana University School of Medicine. But, since most schools around the country closed in March as the virus began to circulate more widely, it's really an unanswered question.

"Schools will now be the experiment," Carroll says. "We're going to see a bunch of schools open with varying levels of control, and then we will see what happens."

There are a handful of preliminary studies from other countries that suggest there's less transmission of the virus from kids to adults or kids to other kids, especially among younger children.

For instance, a study from Switzerland included children who were diagnosed with COVID-19 at a hospital in Geneva. Contact tracers identified the children's household contacts. They found that the child was the suspected spreader of the virus in only three of the 39 cases.

Another analysis from Australia included nine students and nine adults, who were infected with the coronavirus and came into contact with more than 700 other students and more than 125 staff members. The researchers found that only two infections were known to be linked to these exposures.

In a commentary published in Pediatrics, two pediatric infectious disease experts concluded that while these studies are "far from definitive, the [research] provides early reassurance that school-based transmission could be a manageable problem."

However, as testing of children has increased, scientists are learning more. Just last week, a top health official in Victoria, Australia, cautioned that child-to-child transmission is "more apparent" than was previously understood, as more kids have started to be tested.

Other recent research suggests that the age of children may be a factor. Data from contact tracing in South Korea suggest that older children are more likely to spread the virus to their close contacts compared to younger children, particularly in a home setting. Researchers analyzed thousands of contacts of about 5,700 coronavirus patients (from January through March of 2020), looking at the age of the first infected person in a household. In homes where the first person infected in a cluster was 10 to 19, about 19% of their household contacts got COVID-19. In contrast, only 5.3% of the household contacts of younger children aged 0 to 9 were known to be infected.

Note: schools were closed during the period of the study, so it's not clear how the classroom environment influences risk.

And, adding to the concern, there are also some signs that reopening schools can increase the spread of the virus. For instance, researchers analyzed what happened after many students returned to school in Germany in late May. While rates of infection did not appear to increase among teachers and staff, the infection rate did increase among students. The study, which is released in pre-print, concludes that the increase may be attributed to the difficulty of social distancing when schools are at full capacity.

But the returning students in this analysis encompassed a mix of grades including many older students. In contrast, the return of groups of younger students in Germany earlier in May did not seem to correspond with increased cases.

Overall, it's difficult to tease out the specific effect of school closures since so many communities around the globe simultaneously took other steps aimed at slowing the spread of the virus, including stay-at-home advisories.

But many experts agree that the rate of community spread is an important factor in determining whether to return to in-person instruction. The more widely the virus is circulating in a community, the riskier it is to open schools.

"It is reassuring that in other countries that successfully did reopen schools, they didn't in general experience large outbreaks in their schools," says Anita Cicero, deputy director of the Johns Hopkins Center for Health Security.

But she points out that these countries that successfully reopened schools had low community transmission on the date they reopened.

"For instance in Japan, South Korea, Finland and France, each of those countries had about 1 or fewer cases per 100,000 people when they reopened," she says. In contrast, there are currently some U.S counties with 80 or more new daily cases per 100,000.

And while there's no standard metric for determining what rate of community spread is too high to have schools open, many epidemiologists say that when a county has more than 25 new cases a day per 100,000, the county is considered in the "red" zone and should consider shelter-in-place advisories, which would include keeping schools closed.

"So we really need to be doing all we can to drive those numbers down so that we can return children to school buildings," Cicero says.

Given the fact that the virus is still circulating widely in many areas of the U.S., experts say school reopening plans must include measures to safeguard students and teachers.

"The way we can do this safely is really by having very strong plans laid out ahead of time as to how to essentially limit interactions," says Dr. Bill Miller, an epidemiologist and physician at Ohio State University.

This is why many school plans call for pods or splitting classrooms into smaller groups to "make bubbles of kids," as Miller describes it, so that you're not crossing groups of kids across different classes. Limiting class sizes also makes social distancing more feasible.

Overall, when it comes to opening schools, "I think the benefits outweigh the risks," Miller says. But, he cautions that many places in the country have infection rates that are spiraling upward. "So it's really going to take a lot of attention and caution, and at any point I think it would be appropriate to pull the trigger and say, no, we can't [open]," he says, or that we need to close schools again.

To have the best chance of successfully remaining open, "schools should consider postponing bringing kids back into the classroom in regions where there is substantial community transmission of the virus," Cicero says.

"This should be a national priority," she says, "It's measurably more important than reopening bars and restaurants."

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Kids Get Coronavirus, But Do They Spread It? We'll Find Out When Schools Reopen

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As scientists study the burden of COVID-19 around the globe, it's pretty clear that despite some cases of serious illness, kids tend to get infected with the coronavirus less often and have milder symptoms compared to adults. "It seems consistently, children do have lower rates of infection than adults," says Dr. Alison Tribble, a pediatric infectious disease specialist at C.S.

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Add dental visits to the list of services you can book now or shortly as cities, counties and states continue to modify their months-long stay-at-home orders aimed at reducing COVID-19 infections and hospitalizations.

Dental offices were largely shuttered across the United States after being advised in March by the American Dental Association and the Centers for Disease Control and Prevention to close their practices to all but emergency care. Many closed entirely.

The hope was that by allowing dentists to continue to treat serious cases - such as intense tooth pain and infections - those patients would stay out of hospital emergency rooms, where medical workers were busy with severely ill coronavirus patients. And because the personal protective gear dentists and other health care providers need was in short supply, routine dental checkups and cleanings were deemed nonessential at least initially.

More recently though, the restrictions against routine care have been loosened in many places. So, is it really safe to go to the dentist now?
Can't completely eliminate the coronavirus transmission risk
Dr. Gregory Poland, an infectious disease specialist at the Mayo Clinic and a spokesman for the Infectious Diseases Society of America, says he thinks some infections in dental settings are likely to be inevitable.

"But the hope is that recommendations for their practices that all dentists should be following will mitigate that risk," Poland says.

The concern about the risk of transmission of COVID-19 during a visit to the dentist is understandable. Dental settings have "unique characteristics that warrant specific infection control considerations," says Michele Neuburger, a dental officer for the CDC's Division of Oral Health and a member of the CDC's COVID-19 Response Infection Prevention Control Team.

"Dental health care personnel use instruments such as dental [drills], ultrasonic scalers and air-water syringes that create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms and other debris," Neuburger says.

Large droplets can land directly on others in the exam room and can contaminate frequently touched surfaces. The spray could also include small "aerosolized" droplets of COVID-19 if a patient has the virus. And those droplets can remain in the air for up to three hours, according to some estimates, and potentially spread the virus to dental staff or the next patient unless stringent precautions are taken - such as providing personal protective equipment for staff and disinfecting the treatment room, instruments and surfaces between patients.
No cases of COVID-19 traced to dental offices so far
Despite these potential risks, the good news is that both the World Health Organization and the CDC say there have been no confirmed cases of COVID-19 transmitted in a dental office so far. And that includes follow-up by the CDC of news reports suggesting such infections, Neuburger says.

In mid-May, in sync with the American Dental Association, the CDC issued more guidance for dental practices, which continues to be periodically updated.

Ron Greenberg, 62, a computer science professor at Loyola University in Chicago, returned to his dentist in early June. "I have been nervous about going anywhere since mid-March," he says. But when he finally screwed up the courage for his delayed checkup, the dental office had "lots of procedures in place" that made him feel better. A member of the staff called with a list of questions about his health a few days before the appointment, then again on the day of his checkup.

Greenberg was told to call the receptionist from his car when he arrived and then wait to let a staffer open the office's front door - so he didn't even need to touch a doorknob.

"They led me straight to the hand sanitizer," he says. "Next was a temperature check. ... Everybody wore masks until I had to take mine off for them to work on me. And the hygienist and dentist had full face shields for when they were working close in."

Greenberg says he was confident enough after experiencing all those extra precautions to schedule a follow-up appointment for several days later to repair a chipped tooth.
CDC guidelines: Avoid powered tools where possible
Greenberg's visit included many of the precautions recommended by the CDC. These, edited for clarity, include:

Screen patients before each appointment, and when they arrive, for symptoms of COVID-19 - such as cough and fever - and postpone if they have symptoms that could indicate they have the virus.

Use each patient's car or a spot outside the office as the waiting room.

Remove items such as toys, magazines and coffee stations [which can be infection sources] from waiting rooms.

Require masks for patients and anyone with them while in the office area and immediately after procedures and checkups.

Place a plastic or glass barrier between patient and reception staff.

Avoid using powered tools when possible - some practices no longer use a polisher for teeth cleanings, for example.

Leave out only the tools needed for each individual patient so other tools cannot potentially become contaminated.

Use rubber dams over a patient's mouth for procedures when possible to limit spray of secretions.

Use multiple dental workers when doing aerosol-generating procedures when possible to speed up the visit and minimize exposure.

Install high-efficiency particulate air filters to improve room filtration, which might, research suggests, reduce transmission of airborne particles of the virus.

Although a weekly survey by the American Dental Association of dental practices nationwide found that their volume of patients had reached 65% of pre-COVID-19 levels as of June 22, dentists know at least some patients continue to be worried enough to stay away, even if they're in pain or overdue for important procedures such as gum surgery.

Delaying checkups or care for dental pain can potentially turn a small cavity into a root canal or tooth extraction and add to treatment time, higher costs and even more pain, says Howard Golan, a dentist in Williston Park, N.Y., who recently reopened his practice after seeing patients only for emergency care since mid-March. In rare cases, he says, missing out on dental care can result in serious infections and even death.

Dentists have a vested interest in taking all possible precautions.

"Dentists are typically 12 to 18 inches away from their patients," says Louis G. DePaola, associate dean of clinical affairs at the University of Maryland School of Dentistry in Baltimore. "To do their work dentists have to lean close in to what currently is the most infectious part of a person if they have COVID-19 - their mouth."

Protecting the health of others working in the office is paramount, too.
What about the orthodontist?
Daniella Smith of Silver Spring, Md., saw her dentist for a cleaning in late May, and that's when she also resumed orthodontist visits for her two children, ages 12 and 15.

"I was pretty impressed by all the new measures," says Smith, including staff opening all doors and not using the high-powered polisher during her cleaning. The kids were advised to brush their teeth just before coming to the office, to cut down on saliva being sprayed during an appointment.

"With all the time and money spent on the kids' braces, we really didn't want their teeth to move back," Smith says, "which is why we made appointments when the office opened back up."

Ideally, dentists would test their patients for the coronavirus ahead of their appointments and reschedule anyone who tested positive. But the "point of care" tests that can give results in about 15 minutes can produce false results, says Marko Vujicic, chief economist and vice president at the American Dental Association's Health Policy Institute.

"We're keeping our eyes on testing to see if there will be an effective way we can truly determine the COVID status of patients before treatment," Vujicic says. "Until then, we are advising dentists to take an abundance of caution according to the guidelines when it comes to treating patients."

"I think everyone is looking for the best science as we go forward," says Connie White, president of the Academy of General Dentistry and interim dean for clinical programs at the University of Missouri-Kansas City School of Dentistry. The National Institute of Dental and Craniofacial Research is soliciting coronavirus-related research proposals on, among other things, ways to improve disinfection and prevent disease transmission.

Meanwhile, White and other dental leaders also say they realize continued upticks in coronavirus cases across the U.S. could result in dental offices being told to shut again in certain regions.

"I hope that's not the case, of course," White says. But with openings and closures in flux, it's a good idea to make sure any dental procedure begun during one appointment can be concluded soon thereafter. "Patients should discuss with their dentist what is necessary to do right now and what can wait," White advises.

Remember, infectious disease specialists note, that we all have important responsibilities as patients, too, to let the dentist know before or on the day of the appointment if we're feeling sick in any way. We're all in this together - if you're sick, stay home.

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The Dentist Will See You Now. But Should You Go?

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Add dental visits to the list of services you can book now or shortly as cities, counties and states continue to modify their months-long stay-at-home orders aimed at reducing COVID-19 infections and hospitalizations.

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America is suffering through two insidious and deadly pandemics, one brought forth by a novel virus and the other by a long-overdue reckoning of the intransigent racial and ethnic disparity at every level within all of our systems.

Nowhere is this more evident than in our public schools, where nearly 50 percent of children come from communities of color, and with nearly one-third of Black children and one-quarter of Hispanic children living at or below the poverty level. It is precisely these students who are trapped in the crosshairs of both pandemics: the coronavirus having laid bare inequities in health risk, access to virtual education platforms and basic safety both in and outside of their homes-all factors compounded by the profoundly damaging effects of poverty and racism.

Educators, scientists, public health experts and policymakers have spent decades-rightly, though with varying degrees of success-on optimizing the educational environment for children, by focusing on safe, culturally responsive and engaging classroom environments that meet the needs of diverse learners and develop the whole child. As a behavioral geneticist focused on the mind-body effects of stress and the development of resilience, I believe it is clear that in order to do this well, we must also focus on optimizing the school environment for teachers.

To do this, we look to science, which tells an optimistic story about the powerful levers at our disposal to optimize brain health, physical health and well-being at any point in the life span.

The Science of Human Malleability and Stress

Context matters for all of us, as nature operates via nurture: our genes are merely chemical followers. It is epigenetic processes-the way in which experiences and lifestyle habits change how our DNA is read and expressed-that shape how we look and how we feel, 24 hours a day, 365 days a year. This means that human beings, at any age or stage, are malleable and designed to learn, grow and adapt in order to thrive in changing circumstances.

Over time, consistent repetition-whether it be a child learning to read or an adult starting a new exercise routine-rewires our brains. In other words, skills that once required intentional thinking eventually become second nature and automatic. Development and reinforcement of wellness-related skills, habits and mindsets for teachers-the leaders in establishing classroom conditions-have been overlooked in creating contexts to help our children thrive. This includes programs and resources that help our educators manage stress and promote emotional, mental and physical health, as the first necessary step toward that larger goal.

Reported stress in the lives of our educators was high before the pandemic and before the murders of George Floyd, Breonna Taylor, Ahmaud Arbery and others led to weeks of protests and a national reckoning.

In 2017, the American Federation of Teachers' Quality of Work Life survey revealed that 61 percent of educators feel stressed "often" or "always" at work, on par with that of physicians and nurses, according to a separate Gallup poll.

Now, in 2020, teachers are living in a veritable tinderbox of stressful conditions. Starting overnight in mid-March, the world was transformed, and reported morale has plummeted ever since. The global pandemic forced widespread school closures, requiring immediate mastery of new technology-described to me by one middle school educator as "four times the work for a hundred times less joy"-and, for many, requiring simultaneous instruction of students while managing toddlers and school-aged children at home. These issues layer atop pernicious fears surrounding the health of self (nearly one-third of all teachers are age 50 and older and at higher risk for COVID-19), family and friends-and economic survival.

Moreover, and of greatest consequence, teachers-and all human beings-are faced with the moral imperative of our age: how to begin to right the persistent wrongs of racial injustice and structural inequality around the globe and in our own country, neighborhoods, classrooms and homes.

These dynamics are all playing out under a looming shadow of uncertainty about practically every aspect of education as we know it today, creating a profound sense of anxiety and fear about the future, and what returning to school in person will mean. The American Academy of Pediatrics' "strong recommendation" that students be " physically present in school " where possible, emphasizing the magnified health, social and educational risks of keeping children at home, underscores the dilemma teachers are caught in the middle of-how to support their students amid this crisis and also stay healthy themselves.)

Indeed, for most of our 3.2 million full-time educators in the United States, personal stress is at epidemic levels.

To buffer stress, and both create and sustain the necessary conditions for emotional and physical healing, education systems and individual schools must prioritize teacher wellness as the first step in student recovery. Why? The answer lies in our biology.

While stress is a necessary and important factor in human development, and positive stress ("eustress") helps us rise to the top of our game, unbuffered chronic stress releases neurobiologically toxic levels of chemicals into our physiological systems that can alter brain structure and function, and impair immunity.

In the context of widespread violence and protests surrounding racial injustice, economic uncertainty, the new complexities of school life and home life, compounded by the invisible, unpredictable, unrelenting and life-threatening realities of the coronavirus-the latter terms ironically ones that accurately describe the effects of racism-it is obvious that educators, particularly our teachers of color, are weathering the "perfect storm" of conditions for stress-driven mental and physical illness.

Neutralizing Stress

Now, some good news.

It is possible to neutralize inflammatory stress biochemistry. When this happens, our sympathetic nervous systems (which direct us to fight, take flight or freeze) can get settled instead of getting triggered, allowing us to act, rather than react.

Feeling a sense of control broadens cognitive perspective by allowing us to key off of moments that fuel our emotions, like joy, contentment and authentic human connection, in a way that broadens our thought-action repertoire. In other words, it helps us see the proverbial forest for the trees and fosters development of adaptive and flexible strategies that increase the effectiveness of stress management and decision-making both inside and outside the classroom.

By focusing support on the emotional, mental and physical well-being of teachers, we amplify their capacity to place their own oxygen masks on first. They, in turn, will be able to direct their energy toward developing the kinds of high-quality, safe and trusting relationships with students that are the vital emotional scaffolding upon which all else is built.

With relationships as the vehicle, teachers can begin to develop and instill classroom practices and curricula that address COVID-related learning loss, foster academic re-engagement and bolster student health and well-being. Bottom line: Teachers cannot help to stabilize their students nor their classroom environments unless they are healthy themselves.

Three scientifically grounded approaches offer solutions and must be institutionalized into the school day.

Positive Lifestyle Practices

First, we must integrate scientifically grounded mental and physical health supporting lifestyle practices that serve as Mother Nature's oxygen mask. These include prioritizing high-quality sleep, engaging in regular physical activity and making healthy nutritional choices, all which promote health and build immunity.

Other essential elements include meditation, breathwork, yoga, cultivating and maintaining high-quality relationships, and intentional reinforcement of mindsets that promote human connection, such as gratitude, altruism and collective efficacy. What's real in the mind is real is real in the body, and it is our perceptions-not "objective" reality-that drive our biochemistry. Accordingly, finding a silver lining-even under the most dire of circumstances-instigates a biochemical " upward spiral " which fosters constructive thinking in a demanding moment and, over the long-term, protects health and psychological well-being.

Professional Learning

Second, teachers need ongoing professional training to develop social-emotional competencies, strategies for self-regulation, healthy collaboration and stress management. Emotions are contagious-for better and for worse-and underlie both learning and retention at all ages and stages on the developmental spectrum. Hence the critical need to focus on improving the health of the entire relational dynamic system that exists within a school. This includes classrooms, teacher break rooms, hallways, the counselor's office and playgrounds-all of the places where learning happens.

Equipping teachers with skills that build emotional intelligence empowers them to " pause, reflect and label," fortifying thoughtful, intentional leadership and interaction with students and colleagues alike. Investing in the kinds of healthy emotional climates that enhance all higher-level cognitive processes (e.g. executive function, attention and self-regulation) is a non-negotiable requirement for the flourishing of relationships and outcomes-academic and otherwise-within a school.

Mental Health Support

Third, teachers must have access to mental health resources during and after the school day. These include regular organized support groups, opportunities to connect with tele-mental health providers, no-stigma mental wellness days and coaching to set reasonable expectations in balancing responsibilities both inside and outside of school.

Given the extraordinary convergence of stressors related to home life, work life, economic stability and public safety, teachers need access to trained mental health professionals to ground and re-center, particularly in light of mental health issues presenting as the " second wave " of COVID.

By creating routines that promote health and reduce stress, and by prioritizing high-quality supportive relationships, teachers can build resilience-arguably the most important skill we can both embody and also model for our children and students during this chapter in time. The new 3Rs (relationships, routines and resilience) can restore a sense of control amid uncertainty and equip young people with skills and mindsets that pay dividends-on myriad developmental levels-for life.

Do the above strategies represent a revolution in schools' current practices and policies? In a word, yes. But we are at an inflection point in our country's history, during which capitalizing on great opportunity means leaning into great challenge.

It is time to innovate, have courageous conversations about race, equity and social justice, and be both strategic and intentional to catalyze bold ideas into action. In doing so, we can reflect on this double pandemic as a time when we successfully leveraged two all-consuming crises to strengthen our educational system by narrowing the false divide between public education and public health, and implemented the 21st century science of learning and development to optimize conditions for both teaching and learning.

We can and must create a healthier, more productive, equitable and effective educational system-one that protects our teachers, lowers attrition, motivates new educators to enter the profession and gives all of our children the mindsets, support, tools and skills they need to flourish, reach their full human potential, have hope for the future and live the lives they choose and deserve.
Sheila Ohlsson Walker, CFA, Ph.D., is a Senior Scientist at the Institute for Applied Research in Youth Development at Tufts University and a Visiting Professor at the Johns Hopkins University School of Education.

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Teachers Are Living in a Tinderbox of Stressful Conditions. These Scientific Approaches Can Help. - EdSurge News

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America is suffering through two insidious and deadly pandemics, one brought forth by a novel virus and the other by a long-overdue reckoning of the intransigent racial and ethnic disparity at every level within all of our systems. Nowhere is this more evident than in our public schools, where nearly 50 percent of children come from communities of color, and with nearly one-third of Black children and one-quarter of Hispanic children living at or below the poverty level.

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Please Note

The Washington Post is providing this important information about the coronavirus for free. For more free coverage of the coronavirus pandemic, sign up for our Coronavirus Updates newsletter where all stories are free to read.

As Americans learn to live with the coronavirus, many are struggling with decisions about which practices are safe or risky for them. The Washington Post asked six public health/infectious diseases specialists about their own behavior choices.

Questions & answers

Q: When and where do you wear a mask?

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases: It dominates everything I do. The only time I don't wear one is when I am alone, when I am home with my wife, or when I am speaking in public - provided there is 6 feet between me and the people to whom I am speaking, as was the case when I answered questions at the recent Congressional hearings.

Elizabeth Connick, chief of the infectious diseases division and professor of medicine and immunobiology at the University of Arizona: I walk in the morning and never wear a mask walking around in my neighborhood. Even if you see somebody, you can keep your distance. But I do wear it otherwise. I don't wear one inside my own office, but I do wear one in the general office area. I wasn't wearing one before, but now everyone is masking because we have more covid spread [in Arizona].

Paul A. Volberding, professor of medicine and emeritus professor of epidemiology and biostatistics at the University of California at San Francisco: I wear a mask most of the time, although not inside the house or sitting outside on my second-floor deck. I think people are crazy not to be wearing masks. The evidence that they are effective is pretty strong. I've noticed in recent weeks that the number of people wearing them seems to be decreasing, which concerns me. There is no shame in wearing a mask.

Linda Bell, South Carolina's state epidemiologist: I wear one in public whenever possible, in stores, office settings, if I encounter groups of people that I can't distance myself from and during press conferences when I'm not speaking.

Barry Bloom, Jacobson research professor and former dean of the Harvard T.H. Chan School of Public Health: Every time I leave the house, inside and outside, and certainly when I shop.

David Satcher, former U.S. surgeon general, former director of the Centers for Disease Control and Prevention, and, most recently, founder of the Satcher Health Leadership Institute at the Morehouse School of Medicine: All the time. Even when I'm in the office, I keep it on, since people are always coming in and out. The only time I don't is when I am home.

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Q: Besides family, do you allow anyone else inside your home, such as cleaners or service people for repairs?

Fauci: The only person who comes into the house besides (my wife) Christine and me is the woman who cleans the house once every two weeks. She wears a mask and gloves at all times while in the house.

Connick: I pay someone to clean house. She was very afraid at first, and didn't come for six weeks, but I paid her anyway. Then she decided she was comfortable and came back. I'm not here when she cleans, and she's gone when I come home. So I am not breathing her air. I do have a pest control guy come. He's quick, and I stay far away from him.

Volberding: We have cleaners who come once a week. They text me when they are nearly here, and (my wife) Molly and I close ourselves into a room on the top floor study and don't interact with them at all. They text when they are leaving. They are good about disinfecting. As for the room we stay in, it's my chore to keep it clean.

Bell: I allow repair workers in the home and don't make them wear a mask while they're working, but I do when I have contact with them, and I keep my distance.

Bloom: Yes, but only people I know, and we keep our distance and often wear masks.

Satcher: Yes, probably more than I should. My daughter is upset at the number of people I let in who don't wear masks, although I wear one.

Q: Do you shop in grocery stores, or order online? Do you wash the items off or disinfect the outside of packages once you get home?

Fauci: I do physically go to the grocery store, but I wear a mask and keep my distance. I usually go at odd times. I spend half the day alone in my office, and I'm part-time at the White House. In the late afternoon or evening, when I'm finished with the White House, I go shopping for groceries, or to drugstores. I don't disinfect the bags. In general, I will take the materials out of the bags, then wash my hands with soap and water, and then use Purell, and let everything sit for a day.

Connick: I wear a mask when I shop, and stay away from people while in the store. I try to minimize my trips. As infections become more widespread, I think I will be more conscientious about making only one visit a week. I don't wash the packages. I did that for about a week, then decided there would be more cases if the virus was transmitted that way. I don't think there is a lot of virus hanging around on those packages. But I do wash my hands.

Volberding: We have wonderful stores in our neighborhood that really enforce everything. They don't let you get close to anyone else and everyone wears a mask. I don't disinfect or wash anything. I don't think the evidence for surface contamination is real. I don't wear gloves in the store, but I wash my hands before I go and when I come back.

Bell: I shop in grocery stores and order online. I don't disinfect packages that I bring into my home.

Bloom: I shop at grocery stores, and also have them shipped. I don't wash them, but usually let them sit for a day before I use them. The bug dies pretty quickly.

Satcher: I shop in grocery stores and I wear a mask. I do the handwashing thing. I'm compulsive about that. I don't wash or disinfect the packages, but I do wash my hands after touching them.

Q: Would you dine inside a restaurant? Outside? Do you get takeout?

Fauci: We don't do anything inside. I don't eat in restaurants. We do get takeout.

Connick: No, no restaurants. I avoid any closed space with a lot of people, particularly when it's people whose risk I don't know. I think the biggest risk is being in a closed space and breathing the same air that other people are breathing, and also not wearing masks. I wouldn't go even if they were wearing masks. I might consider dining outside, although I would rather not. I think being outside is much safer. Takeout, yes. I would die if I didn't do takeout.

Volberding: I wouldn't feel comfortable yet with indoor seating, but I'd feel comfortable outside, with distances between the tables. We haven't gone yet. We've gotten takeout a couple of times. We are cooking a ton, and love it.

Bell: I would not dine in a restaurant, but I would dine outside if the restaurant had a safe set up. I do get takeout.

Bloom: I would not dine inside now. I would dine outside. I'm a big believer in outside, that it's safer outside.

Satcher: I have not dined inside a restaurant in a long time, and I used to do it a lot. I have not dined outside, but I would if I could be six feet away from other people. I do sometimes get takeout.

Q: Do you take any precautions with your mail or packages?

Fauci: I used to, but now I just bring the mail in, wash my hands, then let it lie around for a day or two before I open it.

Connick: I'm just not that interested in my mail. It's in a locked box across the street from my driveway, and I only pick it up once a week. If there is any virus on those letters, it gets cooked off. I don't think a virus is living on my mail, and I'm really not worried about it. I don't worry about packages. I open them.

Volberding: I don't take any precautions with my mail. As for packages, there is no contact with the delivery person. I don't leave them outside - they'd be stolen if I did.

Bloom: I let them sit for a day. That's probably irrational, but I do it that way.

Satcher: I'm so compulsive about mail that I'm reading it before I get it into my house. But I do wash my hands afterwards.

Q: Do you go to friends' homes for dinner, or have friends to your house, or see them in other ways?

Fauci: On the rare occasion when we have people over, we have them out on the deck, six feet apart, and we never have more than two people, and they are people who themselves are locked in. We wear masks, unless we are eating. We don't share anything. There are no common bowls. Each person has his or her own receptacle. Some people even bring their own glasses. We always do takeout and I tell the takeout people that I want the food in four separate plastic containers, so no one has to touch anyone else's food. Everyone's food is self-contained. Also, we always stay outside. We don't do anything inside. If it's too hot, or rainy, we cancel it.

Connick: There are a few friends I see for dinner. In Tucson, you can sit outside to eat. I've had a few people over to dinner and we eat outside. I don't have many people over. The people I have over have been quarantining. We don't wear masks. We sit outside at a good distance. I think if you are outside at a good distance the risk is very small. I invite over people who are very circumspect in their behavior. No one comes over to my house who goes to restaurants or bars.

Volberding: Except for seeing immediate family, the only thing we have done was to go to a birthday celebration for a friend in Golden Gate Park. Everything was widely spread out, and everyone was wearing masks. Everyone brought their own blanket and food. We haven't been in anyone else's house, and no one has been in ours, except our kids, and only once in a while.

Bell: I don't go to friends' homes for dinner at this time. I do see friends by practicing physical distancing and using masks if we have to be closer than six feet for longer than a few minutes. I allow friends in the home whose practices I'm confident in.

Bloom: I have only seen friends once, to dine outside, which was very nice. I am very keen on the outside and dispersion of aerosols sitting in the open air, but concerned about them in closed settings.

Satcher: I have not been to anybody's house for dinner since this started. My son and his family came over for the day, and my daughter was over once to help me with a Zoom presentation.

Q: Are you getting your hair cut?

Fauci: I usually get it cut every five weeks, but I didn't go for a long while. By the 11th week, it was looking really bad. So I asked the woman who cuts my hair if I could come in really early in the morning, at 7 a.m., and we arranged to do that. No one else was there. She wore a mask and I wore a mask.

Connick: I do not go to the hair salon. I pay my hairdresser to come to my house. The first time he did it, he said: "It's on me, thanks for being a health-care worker." The second time, I insisted. He did it outside the first time, the second time, inside. He comes once a month. No mask for my hairdresser or me in the past. However, now that salons are open, I will have to ask him how much time he has spent at the salon. If he is spending a lot of time, I may ask him to mask. We will definitely do hair outside next time. The pandemic is unfortunately ramping up in Arizona, and everyone's risk is greater now than it was two months ago when he first cut my hair.

Volberding: [laughs] I am quite bald. I have a little hair on the sides and I buzz that off myself. I know Molly would love to get to the hair salon. She took some kitchen shears a couple of weeks ago and whacked off her hair. I understand the urge to get back to some of those personal services, but I haven't been inclined at all.

Bell: I have not, but I would go if the business only allowed one client at a time in the general area, there was no waiting with other clients and the use of masks by all employees was required.

Bloom: Nope, I haven't in three months, but that's because the barbers were closed down. Now you have to make an appointment, and I haven't had the time. Everybody wears a mask, so it would be fine.

Satcher: I haven't been to the barber since this started. I cut my own hair now, just like I did when I was in college.

Q: Are you willing to fly? What about bus, train, subway?

Fauci: I'm 79 years old. I am not getting on a plane. I have been on flights where I've been seated near people who were sneezing and coughing, and then three days later, I've got it. So, no chance. No Metro, no public transportation. I'm in a high risk group, and I don't want to play around.

Connick: I would only fly if I had to, for an emergency. I would not fly now for pleasure or work. I have a family reunion that happens every year, and I'm not going. But if I had to fly, I would wear an N95 mask.

Volberding: I haven't flown, and I'm not eager to. I don't like the idea of being in an enclosed space, especially when the airplanes are full. I've only ridden BART (Bay Area Rapid Transit) once because we were in the East Bay to see our new granddaughter, and a Black Lives Matter protest took over the Bay Bridge. There was no way to get back except by BART. Normally, I wouldn't have done it, but it wasn't very crowded.

Bell: No. With the current disease activity in the country, I don't know when I'll fly again while airlines don't require physical distancing and masks required for all. No [buses or trains], but public transport isn't widely used in my community.

Bloom: No, none of them, not until the numbers of cases are down to much lower levels than they are at the moment.

Satcher: I am willing, but I haven't flown recently. If someone invites me to speak, and I can speak by Zoom, I do it. If someone said they really needed me somewhere, I would go, but I would wear a mask all the way. I have not been on the subway since this started, but Atlanta isn't as big on subways as New York or other places. I just usually drive my car.

Q: Would you visit your kids/grandkids?

Fauci: My middle daughter, who teaches school in New Orleans, drove up here after they closed the schools. She could teach online from here, so she thought: Why not come home and see her parents? When she got here she went straight through the back entrance into the basement. She stayed in our basement, which has a room with a bed, a shower, electricity, and she did not come upstairs for 14 days. My wife brought food down to her on paper dishes. She lives in a very high risk city, and she wouldn't let us near her. I wanted to hug her when she arrived, but she said: "No way, dad." She came upstairs after 14 days, and then stayed with us for several months.

Connick: I'm not going to go visit him [a son, 22, who lives in New York City] because of the flying. Besides, who wants to go to New York when you can't go anywhere? Also, I wouldn't take the bus or subway there. Those are enclosed spaces where you share air, and I avoid them.

Volberding: Not very often. At first, we didn't at all. We have family cocktail hour Zooms twice a week. We talk a lot about covid, and everyone is being super safe. I held my granddaughter - I couldn't help that - but I don't hug my kids or their partners.

Bloom: I have a brand new grandson, 2 months old, who lives in Los Angeles. He's the cutest kid in the world. I would love to fly there and see him, but I won't.

Satcher: I've visited my son and daughter-in-law once or twice. They needed me to sign some papers, so I went over. We were social distancing in the garage area and wearing masks, and my grandkids were wearing masks. We also do family Zoom meetings every other week on Sundays which include my two brothers and sister and their children.

Q: What would you tell your kids or grandkids who wanted to join a protest march or go to a political rally?

Fauci: My daughters feel very strongly about social injustice, but would not likely want to do that. They are very careful with their health. They stay away from crowds.

Connick: I'd be so proud of him. I would tell him to wear a mask. He's young and doesn't have any health conditions. Nothing is risk free. If that's what he wanted to do, I'd ask him to wear a mask.

Volberding: We are a pretty political family, and believe in these protests. But I haven't been to a rally. I'm old enough that it's probably more serious for me. They are young enough that it's probably less serious for them. But I would tell them to stay to the side and wear masks all the time, and that being in the mosh pit of a crowd is a pretty bad idea.

Bell: I would advise them that the risk for exposure is high, and that they should wear a mask at all times, and make every attempt to distance themselves from people without masks.

Bloom: The answer would be yes, but wear a mask and try to stay [six to eight] feet away from everybody. I wouldn't do it because I am at high risk.

Satcher: I was quite active in the civil rights movement when I was a student at Morehouse. I went to jail at least five times. What bothers me about today's protests is that they aren't as organized as we were. You don't know who you are marching with. You don't want to find out when you get there that someone is going to throw a rock or start a fire.

Q: Would you go work out at a gym? Swim in a pool? Run? Walk?

Fauci: I wouldn't go to a gym. I need to be so careful. I don't want to take a chance. I have a pool at home, so I swim in that. I do power-walking with Chris. I was running until about a year ago, but every time I went running, my back would tighten up the next morning. So now I walk the same distance. It just takes longer. We go every day with few exceptions, 3.5 miles per day during the week, four miles over the weekend. Prior to covid-19, I did it at lunch alone in the parks near NIH. Now, I do it in the evening with Chris around the neighborhood. On the weekends, Chris and I do it together on the C&O canal.

Connick: I wouldn't go to a gym. I'd go to an outdoor pool, which is much safer than an indoor pool, since everything dissipates in the air, although I wouldn't go to a crowded outdoor pool.

Volberding: I had a gym built in my house before this and it has everything, so I have no need to go to a gym. But I wouldn't go eagerly. They can't disinfect everything all of the time. As for pools, if anything, outdoors yes, indoors no. The swimmers would need to be far enough apart. There is a lot of heavy breathing, so even if they are in the next lane, I don't think it's fully safe. I try to get out and walk most days.

Bell: Of these I would only run, walk or hike where there were few other people, making it easy to avoid close contact.

Bloom: I'm on the treadmill every other day at my house. I belong to a gym, but don't believe gyms are the safest place to be until the numbers go down. Swimming outside itself is pretty safe - but stay out of the locker rooms.

Satcher: I'm not a gym person, even when there is no pandemic. I have to be outside. Being outside is good for you. I still run and walk, although I walk more than I run. I go about three or four miles most mornings. I would swim, since there is no evidence it is spread in water. I would only swim outside, since I am not an indoor swimmer.

Q: Are you making routine trips to the doctor or dentist?

Fauci: No, not yet, although I might check in within the next few weeks with my physician to get some soothing meds for my throat since I have a hoarse voice from so many briefings and interviews. He will probably take a look and say: "Just stop talking so much."

Connick: Fortunately, I had my doctor checkup just before the shutdown, but I probably would not. As for the dentist, I probably wouldn't go unless I had an emergency. I wouldn't go for a routine cleaning.

Volberding: Nope. I had one doctor's appointment done by video. I haven't been to the dentist, although the problem with dentists is not my health, but theirs. I feel sorry for them.

Bloom: No. I'm still nervous about infection control. If I had a major dental or medical emergency, I would go. The medical people take good precautions, but I am concerned with other patients going in and out.

Satcher: I haven't seen a dentist since this started, but probably will go in soon. I've seen a physician once or twice for routine appointments, and I was comfortable with the way they handled the visits.

Q: What about mammograms? Would you get a routine mammogram/advise your wife/daughter to get one?

Fauci: If routine, I'd probably tell her to wait.

Connick: I am going to do it because I am a year overdue for mine, and want to get it done, otherwise I probably wouldn't.

Satcher: There is breast cancer history in the family, so yes.

Q: What kinds of questions would you ask a doctor's office before going for a routine appointment - and what are "acceptable risk" answers?

Connick: I would ask if they practice universal masking and whether they are seeing sick patients in their office.

Volberding: I would ask about disinfection, masks and face shields, and - for the dentist - whether they are using tools that generate a lot of aerosols.

Bell: I would ask if they separate sick patients from others, whether they keep a physical distance between patients, whether they require the use of masks for all employees and patients in common areas, do they screen health-care providers for symptoms, and exclude those who are ill.

Satcher: I have not interrogated the doctors, because I trust them, and I haven't been disappointed.

Q: Are you working in your office? What precautions do you take?

Fauci: I don't wear a mask when I'm alone in my office, but I slap one on if I walk out into the hall and could pass someone, like my assistant, who also wears one.

Connick: In our infectious diseases clinic, if anyone is sick, they are sent home. They are screened outside and talked to on phone, and asked if they are sick. We see people for HIV or other chronic infectious diseases and they are asked not to come if they have a fever or upper respiratory tract symptoms. Also, everyone must wear a surgical mask or we won't see them. I wear an N95 mask if I am seeing covid patients, as well as goggles and a shield.

Volberding: I still have AIDS patients I do by phone. I went into clinic once a few weeks ago, but stayed only a brief period of time. I'm still not too eager to get back to the clinic. I do most work from home.

Bell: I primarily telework, but I wear a mask in group meetings when I'm in the office.

Bloom: Until recently, school has been closed and locked. I have permission to go in, but no particular reason to do so. I live by Zoom, and it's fantastic.

Satcher: I go in about twice a week and wear a mask all the time, which is the rule. Also, everyone gets temperature checked.

Q: Will you ever shake hands again? Hug/kiss someone?

Fauci: I think it's going to be a while. The infection rate will have to be extremely low or nonexistent, or we have to have a vaccine. Right now, I don't even think about doing it.

Connick: I don't know if people will ever shake hands again. Not until this thing is gone. Not until this is over. If my son came to visit, I'd hug him, but I'm generally not hugging people.

Volberding: It's been a long time since I have shaken a hand. Maybe I will again once there is a vaccine. I grew up in Minnesota where hugging is not common, but since I've been out here, I've wanted to hug people, and love it. Once there is a vaccine, I want to get back to hugging. It just feels normal.

Bell: Yes [to shaking hands], followed by practicing good hand hygiene. Yes [to hugging and kissing.]

Bloom: I'd try to avoid it. I think it's a bad idea. But I would rub elbows.

Satcher: I forget upon occasion and reach out my hand. I'm supposed to set an example, but I don't always remember. Handshakes have always been a big thing at Morehouse, a firm handshake was one of the things they recommended when I was a student. I do the elbow bump thing, and I'm now a stickler for social distance. I don't hug or kiss anyone.

Q: If you had young kids, would you send them back to school in the fall?

Fauci: It really depends on where you live.

Connick: I think that's a very difficult question. I'm very glad I don't have to make that decision. If they got sick, they may be fine but they could give it to me. As a doctor, I feel obligated to not get sick. It would be very difficult [to] have children who were in the school system.

Volberding: Oh boy, that's a hard question. It's such a challenge. The data I've heard about suggest that the really young kids are not much of an infection reservoir, so I think it might be okay for preschool, day care and elementary school. The question gets to be harder in high school and college. I think the schools probably will have shifts, morning and afternoon, and limited hours. They might consider teaching in cohorts - small groups of students, so if one get infected, they can quarantine that one group to keep it from spreading. I don't think you can replace direct interaction with Zoom.

Bloom: Yes. I believe that the process of socialization is really important, and that long-term deprivation of that is probably going to do more harm than the occasional child becoming infected. We also need to liberate parents and get them back to work, but as carefully as we can. I think kids need schooling and socialization.

Satcher: It would depend on what arrangements the school made to protect their health.

Q: Have you been tested for the coronavirus?

Fauci: Yes, every time I go to the White House.

Connick: I have not been tested. I've had no symptoms, so I see no reason to get tested.

Volberding: No. I am asymptomatic. I take my temperature every day and I have a spray bottle of fragrance that I spray into the air every day to make sure I haven't lost my sense of smell. I'm in my house almost all the time except for walks in the neighborhood and trips to grocery stores.

Bloom: No. But I have no symptoms.

Satcher: Yes, Morehouse requires it before we can come back. I actually took two different tests, the nasal swab and an antibody test because I was curious. I didn't have any symptoms. Both were negative.

Q: What is your best guess about when a vaccine will be available?

Fauci: We have multiple candidates, and my hope is that we will have more than one, probably by the end of this year or the beginning of 2021.

Connick: Hopefully in six months. That would be a dream.

Volberding: The challenge isn't making a vaccine, it's in testing it for efficacy in large numbers of people. It's got to be placebo controlled to know it's working, and done on enough people with exposure risk. If everyone is staying at home, you won't know. It also depends on how the epidemic goes. If, unfortunately, it is blasting along, you'll be able to test it. It will take longer if there is a pandemic lull. I'm not expecting anything for at least a year from now.

Bell: Based on previous vaccine development, and the expectation that safety and efficacy were well tested, a complete guess would be late 2021.

Bloom: It's unlikely we will have one that is 100 percent effective. But it would be terrific to have one that's 50 percent effective, which is in the ballpark for flu. You need about 30,000 people to test and I don't think 30,000 people are going to volunteer for each trial. So how many to know it's safe and effective? My guess, though, is that we could have something by the first quarter of 2021.

Satcher: I wish I could say we will have one by the end of this year, but I can't. We may have one in 2021, but I think it's a long shot. Vaccines are not easy to develop, and this virus gives us some real challenges.

What to know about the coronavrus and summertime activities

Why eyes need good care during pandemic

Blood pressure drugs and coronavirus still being studied

The experts

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases.

Barry Bloom, Jacobson research professor and former dean of the Harvard T.H. Chan School of Public Health.

Paul A. Volberding, professor of medicine and emeritus professor of epidemiology and biostatistics at the University of California at San Francisco.

Elizabeth Connick, chief of the infectious diseases division and professor of medicine and immunobiology at the University of Arizona.

Linda Bell, South Carolina's state epidemiologist.

David Satcher, former U.S. surgeon general, former director of the Centers for Disease Control and Prevention and most recently founder of the Satcher Health Leadership Institute at the Morehouse School of Medicine.

Coronavirus: What you need to read

The Washington Post is providing some coronavirus coverage free, including:
Updated July 14, 2020 Show More Show Less

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How Fauci, 5 other health specialists deal with covid-19 risks in their everyday lives

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Please Note The Washington Post is providing this important information about the coronavirus for free. For more free coverage of the coronavirus pandemic, sign up for our Coronavirus Updates newsletter where all stories are free to read. As Americans learn to live with the coronavirus, many are struggling with decisions about which practices are safe or risky for them.

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Congestion, runny nose, nausea and diarrhea are the four most recent COVID-19 symptoms that the Centers for Disease Control and Prevention added to its growing list of potential signs of the novel coronavirus.

The CDC previously said symptoms include chills, fever, muscle pain, headache, sore throat and a new loss of taste or smell. The agency now lists 11 symptoms on its website.

The additions come as health experts continue to learn more about the disease, and care for very ill COVID-19 patients is improving. Even so, the CDC states the current list doesn't include all possible symptoms for the virus.

Doctors have also identified a symptom informally dubbed "COVID toes" - the presence of purple or blue lesions on a patient's feet and toes.
More: How does the coronavirus cause COVID toes or loss of smell? Here's how the immune system reacts.
The federal health agency warns that symptoms could appear 2-14 days after exposure, most commonly around 4-5 days. People who have contracted COVID-19 report a diverse, wide range of symptoms. For some patients, symptoms last months.
Study: Not just two weeks: When he tested positive for coronavirus, he prepared for 2 weeks of misery. Months later, he was still sick. COVID-19 patients may be most contagious one to two days before symptoms appear
Individuals with COVID-19 may be most contagious one or two days before symptoms appear, one study found.

The CDC has maintained that older adults and those who have severe underlying medical conditions, such as heart or lung disease and diabetes, appear to be at higher risk for "developing more serious complications from COVID-19 illness."

At the end of June, the CDC updated and expanded its list of who is at increased risk for getting severely ill from COVID-19. The agency broke from earlier guidance, saying that pregnant women may be at increased risk for severe illness from COVID-19 compared with non-pregnant women.
More: Contributing: Karen Weintraub, USA TODAY. Follow Wyatte Grantham-Phillips on Twitter at @wyatte_gp. Medical care for very ill COVID-19 patients is getting better
Currently, 150 treatments and more than 50 antivirals are being tested in people.

Even after a vaccine is developed, an effective treatment could be crucial - as vaccines may not work for everyone. Some doctors believe a treatment that prevents people from falling seriously ill or needing hospitalization could allow people to resume their "pre-COVID-19" lives.

"Once somebody develops a treatment for the virus, everything will go away," Daniel Batlle, a kidney expert from Northwestern Medicine and professor of medicine at Northwestern University in Chicago, told USA TODAY.

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CDC adds runny nose, nausea to the growing list of COVID-19 symptoms

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Congestion, runny nose, nausea and diarrhea are the four most recent COVID-19 symptoms that the Centers for Disease Control and Prevention added to its growing list of potential signs of the novel coronavirus. The CDC previously said symptoms include chills, fever, muscle pain, headache, sore throat and a new loss of taste or smell.

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I'm hearing a lot of talk about the coronavirus spreading through aerosols - is wearing a mask in a grocery store enough protection? What else should I do to stay safe?
Quick answer first: Going to the grocery store where you and everyone else is wearing a mask and keeping a distance from each other is still considered a low-risk activity. Go get your summer strawberries!

For background, aerosols are tiny microdroplets containing the virus that can be expelled when we talk or breathe and can stay aloft and travel on air currents. It's still unclear how much of a role they play in spreading the virus, but recently more than 200 scientists wrote an open letter asking the World Health Organization to pay more attention to them.

The agency still maintains that the greater risk of spread appears to be from droplets - larger particles, also expelled when we talk or breathe, which settle more quickly and are less likely to accumulate in the air. However, WHO released a new scientific brief on July 9 saying that airborne transmission might be contributing to spread in crowded, poorly-ventilated indoor spaces such as gyms, choir practice rooms and nightclubs. But how much transmission aerosolized particles are responsible for, versus droplets and contaminated surfaces, they can't say for sure.

"What we are calling for is more systematic research to be done in these types of settings," said Maria Van Kerkhove, technical lead for WHO's health emergencies program, at a press conference on Friday. In other words, stay tuned.

Bottom line: It's impossible to rule out that some amount of transmission may be caused by aerosols. If you want to err on the side of caution, here's what some infectious disease researchers say can help minimize the risks:

Face away from people when you talk: When you're talking face to face with someone, you're in direct line of the plumes of breath that come out of their mouths when they speak. "If there's any scenario where I'm face to face, with someone, I move my head off-center so I'm no longer inhaling that direct plume," says Seema Lakdawala, a flu transmission researcher at the University of Pittsburgh. One tip that helps her is to not make direct eye contact with people. It can be awkward, she acknowledges, but "it's not just about protecting myself, but also about protecting other people," since it's possible to shed the virus without knowing you're infected.

Wear your mask properly: Wear a layered cloth mask in public spaces, especially if you're indoors or in a setting where you can't socially distance. Make sure it covers your nose and mouth. This will catch many of the droplets that come out when you breathe or speak and prevent them from getting into the air. Ideally, to take precautions against tiny, aerosolized microdroplets, "we should be masking everyone with better masks," says Abraar Karan, a physician at Harvard Medical School. But the N95 masks that effectively filter most aerosol particles are in short supply and uncomfortable to wear. Karan suggests well-fitting KN95 masks which have similar protection (but make sure your mask isn't counterfeit).

Make the indoors more like the outdoors: "You limit aerosol transmission by increasing ventilation and increasing air circulation - by opening a window, putting on a fan and just moving the air," says Lakdawala, who keeps several fans running at all times in her lab and office space. Moving air disperses the particles in the air and makes it less likely that someone will breathe in a concentrated cloud of infectious virus. Donald Milton, an infectious disease aerobiologist at the University of Maryland and lead author on the open letter about aerosols, also recommends cleaning indoor air, through air filtration and ultraviolet sanitizing light. "You wouldn't drink water downstream from another town without treating it. But we breathe air from other people without treating it," he says.

Limit the amount of time you're in close contact with people: The public health rule of thumb for what counts as an exposure is close contact with an infected person for 15 minutes or more, so uncrowded grocery stores where everyone is masked and moving represents a relatively low-risk situation, both Lakdawala and Milton agree. Hopefully, you're not standing in one aisle for very long, but you're going to shop efficiently, says Lakdawala, "So even if there are fine aerosols that are getting released by somebody who is infected, they're getting diluted out as these people move in air currents." Indoor bars, restaurants and other situations where people are staying in one place for a period of time, and speaking or singing loudly, make Milton more wary. "I don't know how to drink a beer with a surgical mask on," he says. "And I wouldn't go sing at choir practice, OK?"

Keep a buffer of personal space: This isn't just important for the spray of droplets, it may also help when it comes to tiny airborne particles. If you are planning to sit and talk to a friend, keeping a distance of at least 6 feet creates more opportunities for airflow between you and others. "We have a happy hour in our neighborhood where everybody brings our chairs, and we sit on someone's lawn," says Lakdawala. "Everyone is spatially distanced, and we bring our own drinks and talk." Maintaining a distance from others means there's more ventilation and space for air to pass between you, says Lakdawala.

Each precaution adds another layer of safety from aerosolized particles, says Milton. "Wearing a mask means you're putting less virus droplets into the air, sucking less out [of the air]. Keeping distances means there's less of it near you. And having good ventilation or air sanitation means what's in the air is getting removed. All of those things add up to giving you good protection."

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Coronavirus FAQ: How Do I Protect Myself If The Coronavirus Can Linger In The Air?

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I'm hearing a lot of talk about the coronavirus spreading through aerosols - is wearing a mask in a grocery store enough protection? What else should I do to stay safe? Quick answer first: Going to the grocery store where you and everyone else is wearing a mask and keeping a distance from each other is still considered a low-risk activity.

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If you're traveling this holiday weekend or if you have guests coming your way, there's a good chance you live in a state affected by a mandatory 14-day travel quarantine.

As new COVID-19 hot spots erupt around the country, some public health officials said the measures could help contain the spread. But the rules are a patchwork, and enforcement differs state by state.

"We have a $5,000 penalty" for violating the traveler quarantine, Hawaii Attorney General Clare Connors said. "It's a misdemeanor, which means it's punishable by up to a year in prison."

Hawaii is geographically isolated, but officials said they're convinced their tough enforcement of travel rules helped suppress the spread of the coronavirus.

The daily number of new COVID-19 cases in Hawaii has declined into the single digits.

Connors said most people complied with the travel rules voluntarily, but state and local police have jailed tourists and residents returning home.

"Their neighbors report them," she said. "We've had to arrest individuals for violating quarantine. The counties have also arrested individuals. Hawaii County arrested more than 20 individuals about a week and a half ago."

Similar traveler quarantines are now being tried by states across the U.S., but most have different rules about which travelers are affected.

New York Gov. Andrew Cuomo announced Wednesday that travelers from 16 states, including California, Georgia and Texas, are now required to self-quarantine.

During his daily briefing, Cuomo said state officials have begun using information gathered from airline passengers to monitor compliance.

"We then do random checks off that database. They can ask you to Facebook,show the surroundings of the room you're in to make sure it's a residence," he said.

Many states impose fines for violating the quarantine order - in New York they run as high as $10,000 - but Cuomo acknowledged enforcement is a challenge.

"We are not going to be 100% effective," he said. "If you want to really come into the state, you can drive. You don't go through an airport; you don't go through anything."

Complicating matters further is that enforcement often falls to local police working with county health officials, who have to decide how much of their limited resources they can spend on quarantine enforcement.

Don Lehman is spokesman for Warren County, a major tourist destination in New York's Adirondack Mountains that is currently monitoring 21 travelers. He said most appear to be complying with the rules but a major challenge is informing and educating people about which states are on the quarantine list.

"We're actually delivering packets to all the hotels and motels we can get to, flyers with forms to hand out to people who arrive from these states to let them know what's expected of them," he said.

Public health experts said it's still unclear how effective travel quarantines will be. Polly Price, a professor of global health at Emory Law School, said they might help, especially if they convey a sense of urgency to travelers.

"State and local governments don't have the kind of resources to go monitor everyone who might be under a quarantine order," Price said. "We've always relied on voluntary compliance, especially when we're talking about such large numbers of people."

Lawsuits have been filed over some of these quarantines as critics question whether travel restrictions and other public health orders violate civil liberties.

Connors, the Hawaii attorney general, said it's clear states do have the authority.

"Under Supreme Court precedent, when we have a public health crisis, the decisions of state elected officials to exercise their police powers to keep people safe are appropriate restrictions on any constitutional rights, like the right to travel," Connors said.

The Centers for Disease Control and Prevention issued a position paper endorsing state quarantine powers. "To control the spread of disease within their borders, states have laws to enforce the use of isolation and quarantine," the federal agency said.

So far, the Trump administration has declined to coordinate interstate quarantines or set national guidelines. As a result, travelers this holiday weekend will have to sort out on a state-by-state basis whether they're affected.

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Some States To Out-Of-Towners: If You Come Visit, Plan To Quarantine For 2 Weeks

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If you're traveling this holiday weekend or if you have guests coming your way, there's a good chance you live in a state affected by a mandatory 14-day travel quarantine. As new COVID-19 hot spots erupt around the country, some public health officials said the measures could help contain the spread.

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here's what's safe and not safe as you plan your july 4 weekend - cnn

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Here's what's safe and not safe as you plan your July 4 weekend

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It's almost the Fourth of July, and while most of us are used to spending the day with friends at the beach or by the pool, this year we're celebrating a little differently.

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Humans can beat COVID-19 because viruses are simplistic. They can't move anywhere without assistance. Leave them outside in the open air for very long, and many will disintegrate. All they know is how to multiply. The problem, of course, is that the coronavirus is adept at this singular task, and as countries such as the United States have tried to loosen lockdowns and other restrictions, they've been jarred by the pandemic's latest swells.

After months of plateauing at 20,000 to 30,000 new cases per day nationwide, U.S. numbers are rising sharply in 30 states, and overrun medical centers are scrambling to free up beds. In Houston, Texas, where daily cases have surged from 300 to 1,300 in two weeks, health-care workers are moving adult patients to children's hospitals in a desperate bid to keep up with the surges. Other states are facing similar challenges.

"We are quickly reaching that critical level of capacity in ICU beds and ventilators in hospitals in the worst-hit areas," says Purnima Madhivanan, an infectious disease epidemiologist and associate professor at the University of Arizona in Tucson. "Right now, I think the only thing we can think about is at least starting with harm reduction."

More than half a dozen epidemiologists, virologists, and psychologists contacted by National Geographic agree, and said that struggling governments can win their COVID-19 wars-and perhaps avoid further lockdowns-through more unified planning and messaging, steeped with harm reduction. They say much of America's inabilities to waylay COVID-19 stem from humans ignoring our essential advantages over the virus: communication, cooperation, and compromise.

On Thursday, the U.S. Centers for Disease Control and Prevention said it believed 5 to 8 percent of the U.S. population-roughly 26 million people-has already been infected with the coronavirus. Though CDC chief Robert Redfield didn't provide data, his claim mirrors what similar surveys have revealed: Outside of New York City, the hardest-hit epicenter on the planet, total infections are still relatively low. Even assuming that every infection mentioned by Redfield creates lasting immunity- which isn't necessarily the case-exposure to the virus would need to expand tenfold in most parts of the U.S. to establish herd immunity. ( Read why the U.K. backed off on achieving herd immunity through infection alone.)

In other words, the virus still has abundant room to keep spreading. But harm reduction can help stop that from happening. Here's how.

Since the beginning of its outbreak, the U.S. has relied on two options: mitigation via draconian stay-at-home orders, and containment of the virus's spread via testing, self-isolation, and contact tracing. This dual strategy is a bit like using either a chainsaw or a scalpel to build Ikea furniture. It isn't flexible enough to adapt to the ever-surprising coronavirus, and it's easily derailed by misinformation.

For one, governors and news outlets have repeatedly cited adults under 50 as the main cause of the newest surges in COVID-19 cases. But young adults have made up about 25 percent of COVID-19 hospitalizations in U.S. surveys every week since early March, suggesting their infection rates haven't ballooned tremendously. In Texas, one of the fastest growing hot spots, the share of infections among young adults was 50 percent before stay-at-home orders began lifting on May 1, and it has only grown by 3 percentage points since then. Likewise in Maricopa County, home to Phoenix and Arizona's COVID-19 epicenter, the share of cases among young adults has increased only 15 percent.

"When you look at all of the pieces, it kind of makes sense that that's the age group that will have the highest rates," Madhivanan says, given the U.S. workforce skews younger. "Infection rates at the beginning of any outbreak are always concentrated in younger, more active age groups with higher social contact rates...They're the essential workers. They are the working class...They are the ones required to be physically at their jobs."

Yet simultaneously, public messaging tends to tell younger groups that they'll be spared from COVID-19 symptoms and its worst outcomes, which isn't quite right. No rigorous studies support the claim that younger people are more likely to be asymptomatic. On June 25, the CDC expanded its list of people at risk of severe COVID-19 to include all adults-rather than just those over 65-with the caveat that risk increases with age. And while deaths are more common among the elderly, clinical reports from hard-hit places such as New York City and China show people under age 50 often suffer serious consequences from COVID-19 and remain hospitalized for as long as members of older generations.

Young people have always been a part of this crisis, but conveying their risks and roles in this pandemic is difficult, which has bred confusion.

"What they need to appreciate is that they are part of a process of the dynamics of an outbreak," Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said before the U.S. House Energy and Commerce Committee on June 23 when asked about how to get younger adults to comply. "Getting back to normality is going to be a gradual step-by-step process and not throwing caution to the wind."

The problem is getting the message just right, because mixed signals can harm people's abilities to adhere to public health advice. Research shows that conflicting messages can cause mental hardship, and in the absence of credible and consistent information, people often hear what they want to hear and become prone to seeking misinformation.

"When there's an absence of consistent messaging from authorities, many rumors and conspiracy theories can fill the void, and that makes it very difficult for people to figure out what it is that they should do," says Roxane Cohen Silver, a UC Irvine professor of psychological science.

Her lab has shown how relentless news cycles that focus too heavily on the negatives, such as those around the 2014 Ebola crisis or mass shootings, can collectively traumatize the public and even elicit symptoms of post-traumatic stress. Though more research is needed, such signs are emerging with COVID-19, including with "doomscrolling," the binging of worrisome media posts. Cohen Silver's team warned in May that both the media and health experts have a role to play in delivering practical advice about the pandemic's risks without amplifying hysteria and confusion.

"I would encourage people to monitor the amount of time that they're engaged with the media to make sure that they're checking trustworthy authoritative sources," Cohen Silver says.

30 million tests or bust?

Testing is one arena where a clear message could help, but it has taken time to find the right path for the U.S. Early flaws with the CDC's COVID-19 kit caused the country to fall behind on diagnosing new cases, the equivalent of trying to end a fire without water. This spring, one report from well-regarded researchers assembled by the Rockefeller Foundation called for "a dramatic expansion" from one million tests per week to three million tests per week over the course of two months. Combine this testing of roughly one percent of the U.S. population with "high-precision" contact tracing, and the foundation predicted that parts of the economy could restart.

However, that approach would require 70 percent of contacts complying with quarantine, says Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security who wasn't part of the report. If the epidemic grows too big, contact tracing can't be successful, and without adequate contact tracing, the Rockefeller report says the nation would need to reach 30 million tests per week to control COVID-19 without a vaccine. The report dubbed it the "1-3-30 plan."

According to the COVID Tracking Project, the U.S. crossed the three million mark in early June, after hovering near the tally since mid-May. And yet, cases are surging again. What went wrong?

"Yeah, we have had far too much testing, testing, testing mantra without really understanding what that accomplishes," says Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and a coauthor of the 1-3-30 plan. "We need to put less emphasis on the number of tests that are conducted in a given region, and ask ourselves what tests are needed."

"I am deeply worried about approaches that assume we are going to test people who either have no symptoms or no epidemiologic criteria for testing," says Jennifer Nuzzo, an epidemiologist who leads the Johns Hopkins Testing Insights Initiative at the Center for Health Security.

Nuzzo wants more than three million tests per week to root out COVID-19 from the most at-risk populations, such as by instituting universal and regular testing at nursing homes, prisons, and jails. But 30 million tests per week would be impractical, she says, because there are only so many labs in the country that can process the samples.

"To me, if we have to do that level of testing, it represents a bit of a failure ... because that will mean that we have let the epidemic grow to the point where it's just wildly uncontained," she says.

But rather than follow the World Health Organization's benchmark, which was decided by an international panel of top experts, the CDC and the White House said that states can start reopening after falling below 20 percent test positivity. "It's outrageously high," Nuzzo says. Of the 30 states with cases surging right now, 16 have test positivity rates above 5 percent, and others in this unfortunate group are trending upward too.

Trickle-down public health

"I don't see this as a wave anymore. Waves are outdated. We have peaks and valleys," says Osterholm, whose center laid out these scenarios in April.

Such observations have yielded evidence-based interventions that can restrict the coronavirus to low levels, buying time for the development of a vaccine or the other remedies needed to wrangle COVID-19. Yet, flaws in messaging are threatening this progress. Few people noticed two weeks ago when the CDC released thorough guidelines on dining out, because the public health agency has largely disappeared from public view. Mask hesitancy has also crept into the public conversation due to political divides.

"The bottom line is it really is about leadership," says Aileen Marty, a professor at Florida International University who has served as an infectious disease advisor on the local, national, and international levels. All of the experts interviewed for this story agreed on this point, but also said responsibility lands not only at the very top with the White House, but also on Congress and its control of health agency funds and veto overrides, governors and their abilities to coordinate counties and cities, and everyone else down the ladder.

None of the experts believe a second lockdown is inevitable, but the U.S. has returned to the dangerous prospect of overwhelming hospitals, which prevents routine services from going forward. Much of the COVID-19 relief aid expires in July, and our return to enclosed environments where the disease thrives is beckoning as summer creeps toward autumn.

"The reality is the virus doesn't care," Shaman says. "It's just going to do what it does."

Editor's note: This story has been updated to correct the daily new cases for Harris County, Texas.

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Here's how to stop the virus from winning

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Humans can beat COVID-19 because viruses are simplistic. They can't move anywhere without assistance. Leave them outside in the open air for very long, and many will disintegrate. All they know is how to multiply.

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Well, folks, many of us have been staying at home for a while now, and you're probably wondering when you can see friends and family for fun. Various states are attempting to relax lockdown measures, nicer weather is arriving, and it's only normal to miss your loved ones hard. It might be tempting to expand your in-person interactions outside of your immediate household, even though the coronavirus pandemic rages on. How risky is it really to start socializing for nonessential reasons with the people you love? ("Nonessential" means we're not talking about protests against police brutality.)

In mid-April, the White House released guidelines for reopening the U.S., outlining a phased process that states like Washington are modeling. The document suggests that before even considering these phases, states should have a declining rate of virus transmission over two weeks; enough personal protective equipment (PPE); enough ICU capacity for if there's another uptick in cases; and efficient screening, testing, and contact-tracing abilities, especially in places that serve vulnerable populations. Again, this should all be before they consider entering Phase One, which includes some reopening of workplaces but still recommends against nonessential travel for business, for instance. As for gatherings, Phase One limits get-togethers to under 10 people if social distancing can't be guaranteed.

This is perhaps why it's surprising and somewhat alarming to see many states open up that haven't met those basic targets. For example, after Texas started relaxing its stay-at-home order in early May, the Texas Tribune reported that the state reported 1,801 new COVID-19 cases on May 16, its highest one-day total since the pandemic started. After starting to open up, Arizona reported 581 emergency room visits for people with confirmed or suspected COVID-19 on May 23, its highest recorded number so far, according to AZ Central. This isn't to say we can totally attribute these spikes to reopening-things like better testing and more thorough data collection could also be a factor. But it does indicate that many states are far from controlling the spread of this disease, even as they open up.

With that said, most " opening up " refers to businesses, not your social life. Which might leave you wondering: If businesses are opening, does that mean you can start to see your family and friends-the ones you don't live with-again? I wish it were that cut and dry.

When restrictions ease, should you make plans to see friends and family right away?

At the very least, you should continue to follow your state and local guidance, like limits on the number of people who can gather in one spot. Beyond that, the decision about how you move forward in our new normal is really going to be a personal one, Amesh Adalja, M.D., a senior scholar at the Johns Hopkins University Center for Health Security, tells SELF. "The virus hasn't changed biologically. Social distancing has eased because hospital capacity is no longer an issue in most parts of the country," he explains. "It doesn't mean that you're not at risk for contracting it."

You'll have to figure out how much risk you're willing to encounter, which will be based on both your psychological tolerance and you and your loved ones' risk of severe illness. If you're older or have a high-risk health condition, even the White House guidelines recommend that you continue to shelter in place until Phase Three of reopening, which would involve your state meeting all of the prerequisite goalposts several times over and not showing any signs of another uptick in cases. Beyond that, you also need to consider the heightened risks you and your loved ones could pose to other people by extension, like essential employees who are working as you buy your groceries, who may be at greater risk of COVID-19 complications or live with someone who is, etc. Finally, keep in mind that estimating the risks involved here is really hard to do when we don't even know enough about the virus we're trying to avoid.

What do health experts think of expanding our social circles?

SELF reached out to a few health experts to understand how they're thinking of socializing as we head into the new normal of this pandemic. In addition to Dr. Adalja, we spoke with Eleanor J. Murray, Sc.D., assistant professor of epidemiology at Boston University School of Public Health, Tara C. Smith, Ph.D., professor of epidemiology at the Kent State University College of Public Health, and Brandon Brown, M.P.H., Ph.D., an epidemiologist and associate professor in the Department of Social Medicine, Population, and Public Health at the University of California, Riverside. (Responses have been edited for clarity and length.)

SELF: How risky is it to see friends and family at a distance with masks? What about without masks, or without six feet of distance?
E.M.: The least risky way to see friends and family is to stay at a six-foot or more distance, wear a mask, and be outside. You could increase your risk by sharing objects between households-that could be like sports equipment or plates or food, anything where you're passing things around. It would be a little riskier to be inside, it would be a little riskier to be closer, or a little riskier to not have masks on probably, although the mask is not totally certain. We know that N95 masks are good at filtering out the virus and they protect both the person who's wearing the mask and the people around them. Editor's note: This is why N95 masks should be reserved for health care workers who are at greater risk of encountering the virus rather than the general public. But as far as homemade or store-bought fabric masks, we don't really know for sure how much protection those masks offer, and we see a lot of people wearing them incorrectly.

B.B.: Seeing family/friends at a six-foot physical distance and with masks has low risk, particularly if all parties are correctly using masks. It is often more difficult to keep the physical distance than you would think, especially when inside a home. This becomes more complicated when factoring in offers of food/drink, sharing a bathroom, and making sure that children keep their distance from others.

T.S.: At a distance with masks is probably not that risky. It depends on the distance and what you're doing with them and the amount of time spent. As you increase the amount of time spent, you have more of a chance to become infected with the virus, even if it's at a lower load. But when you're distanced from them, adhering to more than six feet and wearing a mask, it will lower the odds of viral transmission.
How risky is eating together?
E.M.: You want to try to avoid sharing objects. If everybody brought their own plates and cutlery or you had disposable plates and cutlery, that could be a good way to reduce the risk. If I were to design the ideal friends-and-family barbecue, it would be one where you have some large space and each family has their own grill, is grilling their food, and you're sitting around in socially distanced clusters on your chairs.

T.S.: You can't eat with masks on. You have to take it off, then you have that potential exposure to the virus if somebody is incubating it. You'd want to make sure distance is being adhered to, you're not sharing utensils, you're using hand sanitizer, and things like that. You'd want to try to increase those other hygiene and distancing methods if you're going to be eating since you can't use the masks during that time.

B.B.: It depends. If you are going out to a public restaurant and eating with others, then it's as risky as the environment. Apart from considering the health of the customers, we also need to consider the safety of the restaurant employees, particularly waiters, bussers, and dishwashers who may be at especially high risk due to high exposure and may also face additional racial and health disparities putting them at higher risk of COVID-19 mortality.

A.A.: Any time people interact, there's a transmission risk for the virus. If you're somebody who's pretty risk-tolerant and doesn't have risk factors for severe disease, you can go to the barbecue, but know that there's going to be a risk. Nothing you do in the era of the pandemic is going to be zero-risk.

Is outside better than inside?
B.B.: In general, I would say that outside is better. One of the reasons for this is that when you invite someone inside, it may be more difficult to keep a physical distance in rooms, hallways, etc., due to lack of space. Another is that when inside, people often are touching surfaces like doorknobs, tables, and chairs, so even if you keep a distance, this can lead to potential transmission from someone who has the virus to anyone touching the surface. Go outside and enjoy nature, but keep physical distance at the forefront of your thoughts. Keep in mind the physical distance between you and your friend/family member, but also the distance between you and anyone else walking at the same time in the same place.

T.S.: What's good about outside is that you'll also have some airflow. Any virus that's being expelled from your mouth as you're talking, even that's not getting caught by a mask, will be dispersed a bit. Outside is not perfect, it doesn't 100 percent eliminate the risk, but it does make it a little bit less risky than inside. If you're inside, you still have the chance for the virus to fall on shared objects or surfaces, so that increases the risk a little bit over being outside.

A.A.: In general, we see less transmission in outdoor settings than indoor settings. Visiting with people or doing activities outdoors is going to be lower risk than indoors, all things being equal.
How dangerous is, say, one hug?
B.B.: A physical hug breaks the physical distance barrier and may lead to the spread of infection. There are plenty of stories of people in the hospital with COVID-19 who are terminal, and rules against their family giving one last goodbye hug because of the risk of infection. So we can see hugs can be dangerous. One hug is enough to spread the virus.

E.M.: It's not easy to quantify. If you're giving someone a hug and they haven't come into contact with anyone in two weeks, and neither have you, it's probably not very dangerous at all. But if they gave someone a hug before you and it's a whole chain of hugs, it could be really, really dangerous. One hug is maybe not a big deal, but a whole chain of hugs can be a huge catastrophe.
What would need to happen in order to interact with our friends and family the way we did before the pandemic?
B.B.: Things may never be the same again due to this pandemic, and in some ways that may be a good thing, particularly due to higher health awareness and also higher awareness of health disparities. We need effective treatment and also an effective vaccine against COVID-19. Once we do get a vaccine, we need people to use it, unlike the low uptake of the seasonal flu vaccine. All people must have access to high-quality health care, treatment, and vaccines, including vulnerable populations who are more likely to die from COVID-19.

E.M.: What we want ideally is for there to be no cases in our area and a good tracking system that would be able to detect any new cases coming in from outside the area. Zero cases is a long way off, so that's probably not realistic. What you do want to see is that your local area is doing a lot of testing so they're confident that they're detecting all of the cases, and that there are few enough cases that they're able to do contact tracing on all of those cases. The capacity for contact tracing is going to vary a lot by area.

T.S.: Short of a vaccine, or being sure that everyone in your family unit has been infected and are immune, there's really not much we can do to go back to normal right now. Editor's note: Experts are still investigating if COVID-19 reinfection is possible.
What kind of "family and friend policies" should people implement as we move forward in this pandemic?
A.A.: You have to look at your own health risks. Are you somebody that's at a higher risk for severe disease? If you're somebody that's immunosuppressed, if you're elderly, you really have to be mindful about your social interactions and about trying to be as mindful as you can about not getting infected because you have a higher risk of being hospitalized or having a severe case. If I were the individual physician of a person who's 85 years old with diabetes, I would say you need to limit your social interactions until there's a vaccine. I might give different advice to an individual patient who's 19 years old with no other medical problems.

B.B.: Practices such as temperature checks, washing hands, and routinely asking people about their health and that of their close contacts can become the norm without too much burden on family and friends. Every person should be equipped with methods to prevent infection among their loved ones.

E.M.: You may be able to do a "pod" or "bubble" approach. This idea is that you, explicitly with your household and one or two other households, enter into this agreement that says we are going to be in contact with each other. In order to allow that, we're going to minimize all our other contacts, and if we do have other contacts, we'll share that information with each other.
What should people know when they're weighing whether or not to meet up with friends or family members?
B.B.: Before meeting up with friends or family members, people should ask about their health and the health of their close contacts, ask about which physical distancing rules people have been following, and discuss using masks for the get-together. They should be aware of the COVID-19 numbers as well. For instance, has there been a recent outbreak in the area? That might lead them to make the decision to have a virtual meet-up instead.

E.M.: You want to be reducing the number of interactions you have with people whose other contacts you're not really aware of. Some of the ways we've been doing that are things like encouraging only one member of the household to go to the grocery store so that only that one person has those indoor contacts.

T.S.: There are a lot of varieties out there. It really depends on how risk averse you are and who in your immediate group of friends or family may be vulnerable themselves or may be living with others who are. When you add anybody in, even if you're doing it outside and trying to minimize that risk, it's not zero. You're taking on the risk of those individuals and whoever they're in contact with, in addition to whoever you and your family members are in contact with.

Ultimately, the risk really depends on your situation and how you're meeting up.

The most low-risk option-again, that doesn't mean it's a no-risk option-seems to be outdoor meetups at a distance with a mask on. Your risk generally increases the closer you get to other people and also if you head inside. It's worth having an honest conversation with yourself, your friends, and your family, to see what kind of risks you're willing to take based on your and their health circumstances, along with the health of your community at large.

"Every time you step out of the house now, you're stepping out into a world where this virus [exists]," Dr. Adalja says. "You're going to have to think about what's essential to you and what's not essential to you."
Related:

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So...How Risky Is It to Hang Out With My Friends and Family Right Now?

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Well, folks, many of us have been staying at home for a while now, and you're probably wondering when you can see friends and family for fun. Various states are attempting to relax lockdown measures, nicer weather is arriving, and it's only normal to miss your loved ones hard.

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At this point, almost every U.S. state has entered some phase of reopening. But although many states opened dining rooms and relaxed restrictions in a push for a return to normal this summer, as certain areas see COVID-19 cases and hospitalizations rise, it seems some may have opened too soon.

Broadly, restaurants are encouraged - or ordered - to reduce capacity and space out tables, but the exact rules vary from state to state, and with no universal guidance, restaurants are left to design their own protocols for creating safe spaces for their employees and customers. It hasn't been entirely successful.

Nearly two months after Georgia became the first state to reopen, including allowing indoor dining, coronavirus cases are trending upwards. On June 3, Texas entered the third phase of its reopening, which allowed all businesses to operate at up to 50 percent capacity, and as of June 12, restaurants were allowed to operate up to 75 percent capacity. The state now has nearly 120,000 confirmed cases, and has experienced a recent surge in cases attributed to young people going out to bars. And since the reopenings began, restaurants in Atlanta, Dallas, Austin, and other cities have been forced to shut down again as employees test positive for COVID-19, begging the question: Even if you can go to a restaurant, should you?

Without a vaccine, there is risk. No one knows how long it will take to create a working vaccine, and although there are promising trials in progress, the head of the World Health Organization's health emergencies program believes a viable vaccine is so far off that the novel coronavirus may just become a consistent part of our futures. And so right now, the decision of whether or not to dine out is personal. It's dependent on the prevalence of the disease in your region as well as individual risk. (Are you at increased risk of becoming seriously ill if you contract COVID-19? Are you living with someone who is?) It also depends on the restaurant's design and safety protocols, and while there is no absolutely risk-free way to eat out right now, according to experts, there are scenarios that are safer than others. Whether you're in a state that has "reopened" or are merely fantasizing about the day you'll sit in a dining room again, the answers to these questions can help you weigh the risks and make an informed decision about when to return to a restaurant and how to behave once you get there.

If your state has reopened dine-in service, does that mean it's safe to go back to eating in restaurants?

With so much unknown about the coronavirus, coupled with its continued community spread and testing that still isn't robust enough to effectively identify and isolate everyone who may be infected, it's premature to declare reopened businesses and lifted restrictions on public life to be 100 percent safe. "I am an eating enthusiast who loves going out to eat with my friends and family, and as much as I'm eager for restaurants to reopen ... we just don't know enough about transmission to really estimate the risk of infection," says Angela Rasmussen, a virologist and associate research scientist at Columbia University.

The question remains: Even if you can go to a restaurant, should you?

But truthfully, there's no such thing as "safe" - if by "safe" we mean "absolutely zero risk" - in environments with other people until there's a vaccine (which may take a very long time) or until everyone has contracted the virus and developed antibodies that confer sustained immunity. Given that "zero-risk safe" isn't possible, and that health concerns have to be balanced with economic concerns (unless, say, the federal government were to offer more direct help to the populace, perhaps in the form of monthly $2,000 stimulus checks), the question becomes: How do we mitigate risks during this incremental process known as reopening/recovery?

It's important to remember the basics of how SARS-CoV-2 can spread: through large viral droplets, through contaminated inanimate objects known as fomites, and, as some studies suggest, through airborne particles, according to Joseph Allen, assistant professor of exposure assessment science at Harvard University and co-author of the book Healthy Buildings: How Indoor Spaces Drive Performance and Productivity. Given these potential modes of transmission, there are a number of factors to consider when it comes to dining out again, like: indoors or outdoors? Mask on or off? Cash or credit?

These are all questions that restaurant owners are thinking about right now as many prepare to reopen, but it's a good idea to ask those businesses what their concrete plans are to prevent virus transmission, says infectious disease epidemiologist and infection prevention researcher Saskia Popescu. And then there are the basic guidelines that everyone should consider: getting updates from your local health department to know whether your area is seeing decreasing cases; continuing to practice good infection-control habits like hand hygiene; and opting for takeout or delivery if you're high-risk or live with someone who is, per Popescu.

Above all, remember that risk is shared: It's not just you at risk of infection here, but your loved ones, other people's loved ones, and an entire community. "I hope that, as a country, we will continue to think about our neighbors, our community members, and those of us who are at higher risk," says Michael Knight, assistant professor of medicine and the patient safety officer at the George Washington University. "As a good neighbor and a good citizen, what role can you take to get some sense of normalcy and to improve our economic conditions, but to also decrease the risk?" That may mean still limiting nonessential trips even if restrictions in your state are lifting - or, at the very least, taking note of the following suggestions to mitigate risk as much as possible.

Are you safer in a bigger restaurant with socially distanced tables than a smaller restaurant with the same protocols?

As people return to dining rooms, social distancing will be essential for restaurants of every size.

A bigger, well-ventilated restaurant with strict limits on the number of people working and the number of people it serves will be safest. "A larger restaurant that can spread out people better and still have fewer staff and have fewer clients will be preferable to all trying to pack in," says Robyn Gershon, professor of epidemiology at the NYU School of Global Public Health.

A report from architects Charles Hemminger and Seth Boor shows what socially distanced tables could look like for restaurants in San Francisco. Changing restaurant layouts to accommodate social distancing will require them to reduce the number of people they serve, and for restaurants that get by on very thin margins under normal circumstances, reducing capacity in this way might not be sustainable financially. Arranging tables six feet apart may be more possible for restaurants with bigger spaces for both logistical and financial reasons, but the number of people in a space increases risk, and by that calculation, a smaller restaurant with socially distanced tables would be safer than a larger restaurant trying to serve as many people as possible under the new rules. "The more people, the higher the risk that someone there is infected," explains Knight. "The No. 1 risk is interacting with someone else who is infected."

However, if a small restaurant doesn't have the space to properly space out tables or safely manage the flow of people, that would cancel out some of the benefit of its small capacity. Restaurants need to ensure "there's enough space to move so that people aren't on top of each other," says Allen. Dining room tables spaced six feet apart is just the first consideration; diners also need to remain socially distanced in waiting areas, bathroom lines, and in multi-stall restrooms. Plus, without proper ventilation, this space becomes immediately unsafe.

Should you be worried about the number of people at your table? How many is too many?

Although the CDC's phase 1 reopening guidelines suggest limiting gatherings to groups of no more than 10 people, some experts caution that dining out in groups that size is still risky. "As things open up, we still need to be safe," says Popescu. "If those are people you're living with, that's fine, but if you're going out to meet eight friends, I worry about the increased risk for that many people."

Consistently, studies have shown that the virus spreads most easily among groups of people in enclosed spaces. Super-spreader events, in which one infected person passes the virus to multiple people, occur when people from different households come together for an activity indoors, whether it's a religious service or a birthday party. Similarly, a large group dinner that gathers people from different households in a restaurant dining room could put everyone at risk.

"You're going out to meet eight friends, I worry about the increased risk for that many people."

Diners can't socially distance while sitting at the same restaurant table, and they can't wear masks while eating, so there's a clear risk of transmitting the virus. Gershon agrees that limiting group dining to people who live together lowers risk. "It would make sense to go out with people that you've been in quarantine with and not introduce ourselves to other people that we haven't been in close contact with over these past several weeks." So while there's no ideal dining party size, if you must look beyond your own household, fewer people at your own table is safer.

How much does a restaurant's ventilation system/airflow really play into things? Should that influence where you sit to limit risk of coronavirus transmission?

We know that the virus spreads when people are in close contact, and according to the CDC, respiratory droplets that are produced when a sick person coughs or sneezes are the most common mechanism for transmission. These droplets don't travel more than six feet from the sick person, which is why social-distancing rules use the six-feet marker.

However, there is also evidence that the virus can spread through small droplets produced during normal activity, like talking or laughing, and while larger droplets fall to the ground, according to a new study published in the Proceedings of the National Academy of Sciences and covered by the New York Times, these small droplets can remain suspended in the air for up to 14 minutes. Additionally, research shows that the virus is aerosolized, meaning it's contained in even smaller droplets called aerosols that can travel through air and, as increasing evidence suggests, can remain in the air for hours indoors.

Back in April, Chinese researchers released the results of a study that showed how air currents from a Guangzhou restaurant's ventilation system carried aerosols to restaurant patrons more than six feet away from an infected diner. The study seemed to suggest that diners should be wary of ventilation systems - and that there might be "safe" places to sit in restaurants.

More recent findings from the University of Oregon may also suggests that air conditioning units and ventilation systems can carry the virus. In a study of the HVAC system in a healthcare setting, the virus was detected in 25 percent of samples taken from units in nine different locations, raising the possibility that viral particles can travel through the air handling system of a hospital, including through high-efficiency filters and into air ducts. The authors of the study believe this has implications for other kinds of spaces, too.

However, there are too many unknowns to take meaningful action (the samples in the University of Oregon study, for instance, were not evaluated for viral infectivity), and ultimately, ventilation does work to mitigate the spread of the virus. Ventilation systems, if constructed properly - meaning that they're delivering fresh outdoor air and recirculating air through a high-efficiency filter - help clean the air. "We've known about these factors for a long time in terms of how they can exacerbate a problem in a building or work to help mitigate disease," says Allen. "It's not so much that an air conditioner or any other system is inherently good or bad, it's how it's being operated and how the air is being delivered."

While it's possible for the virus to be carried in small droplets through the air, airflow can also disrupt aerosol transmission. According to Kevin Van Den Wymelenberg, director of Energy Studies in Buildings Laboratory at the University of Oregon, increasing airflow in a room, whether it's through a ventilation system or opening windows to create a cross breeze, is one of three built-environment considerations that may reduce transmission. There's also evidence to suggest that humidity supports immune function, prevents viral particles from being deposed deep into the respiratory tract, and has been shown to deactivate viruses. And while more data is needed, some preliminary research shows that sunlight can deactivate the virus in the same way it does for bacteria, leading some researchers to advocate for ultraviolet light fixtures that bring this ability indoors. The technology is called upper-room ultraviolet germicidal irradiation and has been previously successful in slowing the spread of diseases like tuberculosis and measles, according to the New York Times.

But it's too soon to declare any indoor dining set-up safe: as long as there is a person in a restaurant with the virus, there's the possibility that it will spread. "If there's one viral shedder in that space," says Van Den Wymelenberg, "there's risk."

Is outdoor or patio seating safer, taking into consideration airflow and exposure to passersby?

The natural ventilation of the outdoors makes it safer than enclosed spaces, and states like Louisiana and Connecticut allowed outdoor dining before moving to open restaurant dining rooms. "There's no way to know how much safer, but anywhere you've got more dilution, it's going to reduce the risk of airborne or aerosol transmission," says Van Den Wymelenberg.

As with indoor seating, it's vital that diners take social distancing into account when eating outside, whether it's on a restaurant's patio or in a park. "Being outdoors is not sufficient itself," explains Allen. "We still have to take these other precautions ... including maintaining physical distancing, managing the flow of people in and out of the space, managing the waiting area, managing the bathrooms. It really has to be this holistic strategy."

While it's feasible to keep six feet of distance between diners seated outside, it may not be reasonable to expect the same distance from passersby in cities where restaurants share sidewalks with pedestrians. But although this technically puts diners in contact with more people, potentially increasing risk, the likelihood of contracting the virus from a passerby who comes within six feet isn't high. Popescu notes that face-to-face interactions for a prolonged period of time (around 10 minutes) are more concerning, and several reports on community spread compiled and posted on Twitter by Muge Cevik, an infectious diseases and virology clinician and researcher at the University of St. Andrews, show that "close and prolonged" contact, not brief interactions, is the overall driver of the epidemic.

Are you safer in a restaurant with fewer front-of-house employees?

The fewer people a diner interacts with, the better. "My biggest focus on risk would be reducing the number of people you're coming into close, prolonged contact with," says Popescu. This includes fellow diners, as well as restaurant staff.

Is there a limit to how long you should spend in restaurants?

The longer you sit in a restaurant, the more opportunities there are to come into contact with other people as tables turn over or shifts change. To avoid crowds, it may also be prudent to consider the time of day you dine. As the New York Times pointed out in a report that used cellphone data to track crowds at various types of businesses, it would make sense to avoid a pancake house during the crowded morning hours. While it's possible to limit your direct contact with people in a restaurant setting, especially at less-crowded times of the day, Knight wouldn't recommend a leisurely meal. "I would recommend having your meal and enjoying it, but keeping in mind that the longer you stay, the higher your risk. You want to balance between comfort and reducing your risk."

That said, there's no point at which the length of time you spend in a restaurant switches from safe to unsafe. As Allen explains, it's a multifactorial issue: the risk of contracting the virus does depend on duration and frequency of contact, but it also depends on proximity and the concentration of the viral load. "That's why there isn't an answer to how long is an acceptable amount of time," he says. "It depends. It's maybe an unsatisfying answer, but that's the reality."

"The longer you stay, the higher your risk. You want to balance between comfort and reducing your risk."

Is fast casual - which may have more people, but less exposure time - safer than a traditional sit-down restaurant?

Once again, it depends. In a fast-casual setting, interactions with staff are necessarily brief and limited, which is helpful for reducing the risk of contracting the virus. However, a fast-casual restaurant that requires you to wait in an area with a large group of people isn't any safer than a sit-down restaurant. And given the number of people who come through a fast-casual restaurant, it's essential that restaurant staff take the appropriate measures to prevent the virus from surviving on surfaces as well. Says Popescu, "My focus would be on the measures they're taking to ensure you can safely dine and maintain social distancing, have access to hand-hygiene stations, and what they're doing to ensure cleaning/disinfection occurs while keeping their staff safe."

When considering the safety of restaurants, the style of dining doesn't matter as much as the measures restaurants take to keep staff and diners safe, including requiring appropriate personal protective equipment, cleaning regularly, and restricting the number of customers while making it possible for them to remain socially distant. "I want to emphasize that it's not just eating at the table," says Knight. "You also have to keep in mind the waiting rooms, the bathroom lines, all of those things."

Should you be wearing a mask and gloves at restaurants? How are you supposed to eat with a mask on?

Experts recommend that you don't keep gloves on when dining out. "You touch the door handle, you touch the countertop - everything you touched with those gloves has now become contaminated," says Knight. Instead, according to infectious disease epidemiologist Popescu, you should "engage in good hand hygiene" - washing hands periodically with soap and water, or cleansing with hand sanitizer - and avoid touching your face, especially while eating.

As for masks, it's best to still wear them wherever you can't engage in social distancing: places like the restaurant entrance, waiting area, or the bathroom, according to Allen.

"Remember, the mask is protecting other people from you," says Knight. "I can envision having my mask on, I come in, I sit down, I sanitize my hands, the waiter comes over, I put in my order, the waiter leaves, and I take off my mask."

But don't try to eat with a mask on, or attempt some complicated ritual of placing your mask back over your mouth after every bite. Doing so "might actually result in accidental contamination or dirtying the mask so it can't be worn again," says Popescu.

Does the temperature of the food or how it was cooked make a difference in terms of safety?

According to the Food and Drug Administration (FDA), the coronavirus is not currently known to be spread through food. As Eater wrote in an earlier guide, restaurants have long been required to follow food safety rules. "Restaurants are already taking specific steps that are enforced by our public health departments to make sure that the risk of foodborne illness is very low, and those steps also reduce the risk of virus transmission," says Knight. If you trust a favorite restaurant to follow proper food-handling procedures, then you needn't worry - and if you're unsure about its practices, you can always check its score on your local health department's website or call the restaurant to ask.

Knight's one caveat is to be cautious about self-serve buffets - not necessarily because of the food itself, but because the utensils used to serve that food are likely to be touched by multiple people without proper sanitation in between. In a list of best practices for food businesses during the pandemic, the FDA recommends "discontinuing operations, such as salad bars, buffets, and beverage service stations that require customers to use common utensils or dispensers."

Should you worry about using utensils, menus, condiments, or other items?

In short, it depends.

"The idea that the virus could be transmitted through inanimate objects, or what we call fomites, is real," says Allen. The virus can remain infectious on surfaces like plastic, glass, cardboard, or steel for longer periods of time - possibly hours or even days, some scientists have found - although the risk of transmission is still unknown, and it's not yet clear how much virus a person has to be exposed to in order to establish infection, according to Rasmussen.

Still, experts recommend that restaurants and customers alike think about ways we can move toward a largely contactless experience, whether that means removing regular menus - which are harder to clean in between customers, compared to sterilized dishes and silverware - and replacing them with single-use paper versions; installing touchless sinks and automatic doors; or using disposable plastic utensils.

At the very least, says Knight, be careful handling condiments and menus that are passed from table to table, or picking up silverware and beverages from a common area. And always be sure to wash or sanitize your hands after touching other surfaces and before bringing your hands to your face.

Can you still use the restroom?

Sure, but you may need to adjust some behaviors in order to maintain social distancing, experts say. Customers shouldn't congregate in lines, restrooms, or other parts of the restaurant without six feet of distance between each other. Ideally, customers would also wear face masks in these common areas. Keeping in mind advice against constantly putting masks on and taking them off while at a restaurant, it's probably best to limit bathroom breaks to the beginning of the meal, before you've removed your mask, or after the meal, when you've put your mask back on.

Hand hygiene also remains imperative (here's hoping you had already made it a habit to wash your hands after using the restroom). The virus has been found in the stool of some people who are diagnosed with COVID-19, although studies have yet to confirm whether or not the virus can spread through exposure to fecal matter, per the CDC. Customers could potentially pick up those fecal particles in restrooms where flushing toilets generate bioaerosols, according to Allen. There are also all the restroom surfaces that you touch, from toilet handles to doors to faucet handles. Restaurants need to make sure that "exhaust fans are operating at high capacity" and do what they can to "make a touchless bathroom experience," says Allen.

But such measures don't diminish the importance of washing your hands with soap and water, or sanitizing with alcohol-based hand sanitizer, especially after using the restroom and before eating.

Are there greater risks associated with cash versus credit card or contactless payment?

In theory, yes, there is a risk, as cash is passed from person to person, but there has not yet been much data on the handling of cash or credit cards when it comes to virus transmission, according to Popescu. Still, contactless payment options are obviously ideal, to avoid having to touch either money or pens and buttons associated with card payment.

Most importantly, though, this question "just emphasizes the need to use hand hygiene and avoid touching your face during these interactions," says Popescu.

If a restaurant asks you for your contact information - say, for contact tracing - can you say no?

It's difficult to give a one-size-fits-all answer to this question, as legal obligations for restaurants and privacy protections for consumers may differ from state to state, says Mark Bartholomew, a law professor at the University of Buffalo Law School. But generally speaking, restaurants - the majority of which are private businesses - can certainly ask for a patron's ID or contact information, and customers can certainly refuse, and restaurants can certainly decline to serve those individuals. As Bartholomew puts it: "It's kind of like, 'No shirt, no shoes, no service.'"

Just because that's technically true doesn't mean that restaurants will necessarily go around asking each and every customer for their personal information, however. Things get trickier when restaurants then have a collection of data that they could potentially retain or share with public health authorities, as one might do for contact tracing in the event of a coronavirus outbreak. But on the other hand, according to Bartholomew, some laws could find a business responsible for allowing in customers with communicable illnesses, without taking proper precautions. "In some ways, it may be appealing for the restaurant to have a flat rule from the local or state authorities saying, 'You need to take everybody's temperature when they come in and keep a record of it,'" he says.

It's prudent to keep in mind that everything remains a moving target, and is subject to change depending on how the situation improves or worsens in different localities. According to Bartholomew, some of these legal concerns could potentially be overridden if governors declare states of emergency that confer powers outside the norm, including requiring businesses to demand certain requirements of customers before serving them.

"Every time that waiters come to your table and interact with you in close proximity, that waiter is being put at risk."

What can you do to help keep your server and other restaurant staff safe?

The fact is that servers and other employees do face increased exposure risks. It's also a fact that their places of work need cash flow so that employees can make a living (unless, again, the federal government were to increase direct support for everyone across the U.S.).

But the very fact that these essential workers are on the front lines of risk makes it even more critical for everyone else to do their part in trying to reduce that risk. That means not going to restaurants or other businesses if you're sick, avoiding touching your face, practicing good hand hygiene, and even asking ahead of time how a restaurant's management is working to protect their employees, suggests Popescu.

It could also mean making a conscious effort to reduce the number of times you have to interact with restaurant staff, since "every time that waiters come to your table and interact with you in close proximity, that waiter is being put at risk," says Knight. As noted earlier, he proposes keeping your mask on until you have spoken to the server and put in your order, and then limiting contact with them afterward.

In Allen's view, the approach to reopening the economy while keeping people safe and healthy can be summed up best as everyone collectively playing an ascribed part. "People going to restaurants should be acting as if they have [the virus] even if they're feeling fine," he says. That could include wearing a mask around other people, keeping physical distance from each other, and being okay with processes taking longer than normal. "We have to do our part to give leeway to these restaurants as they're trying to get back on their feet," says Allen. "It's not just the restaurant's responsibility ... [it's] people coming to the restaurants who have just as much of a responsibility, if not more."

A generosity of spirit should also extend to material generosity. "Keep in mind that the way the restaurant will work to keep you safe is by reducing the number of diners that they have," says Knight. In doing so, restaurants will likely still see lower sales, and servers who depend on gratuities still may not earn as much, so tipping is more crucial than ever. "The waiter is putting themself at risk by serving you," reminds Knight. "Being generous is a good thing."

And if you can't return to dining out during this recovery period - whether because of health reasons, or because you'd like to mitigate the risk for yourself and others in your community - how can you support your favorite restaurants and the people they employ without increasing their potential exposure to the virus? Stay home, order takeout or delivery, and, please, still tip as much as you can.

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At this point, almost every U.S. state has entered some phase of reopening. But although many states opened dining rooms and relaxed restrictions in a push for a return to normal this summer, as certain areas see COVID-19 cases and hospitalizations rise, it seems some may have opened too soon.

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SerhiiHudak/Barcroft Media via Getty Images

Most people who catch the new coronavirus don't experience severe symptoms, and some have no symptoms at all. COVID-19 saves its worst for relatively few.

ICU nurse Sherie Antoinette has seen the serious cases first hand.

The lucky ones - if you can call them that - recover, but not in the sense that their lives are back to normal. For some, the damage is permanent. Their organs will never fully heal.

"When they say 'recovered,' they don't tell you that that means you may need a lung transplant," Antoinette wrote in a Twitter post. "Or that you may come back after discharge with a massive heart attack or stroke, because COVID makes your blood thick as hell. Or that you may have to be on oxygen for the rest of your life."

COVID 19 is the worst disease process I've ever worked with in my 8 years as an ICU nurse.

When they say "recovered" they don't tell you that that means you may need a lung transplant. Or that you may come back after d/c with a massive heart attack or stroke bc COVID makes
- Cherie Antoinette (@sheriantoinette) June 14, 2020

Antoinette's tweet prompted a flurry of responses from former COVID-19 patients, family of patients and nurses working on the frontline of the disease.

We have selected some of their tweets and are running them with minor editing for clarity. SFGATE makes no claims to their authenticity.

I'm currently in the hospital after having a heart attack caused by clotting that resulted from COVID 19. I have a stent in my heart and need to wear a heart monitoring vest at all times. Now I face months of recovery including physical and occupational therapy. I'm only 29.
-Dan

I went into acute kidney failure and needed dialysis. I now have asthma, chronic cough and an irregular heartbeat. I have conditions I never had before, plus I'm wiped all the time. I hope this gets better, but you [Sherie] are on the money. And, mine was considered a low-moderate case.

- Stephanie McCarroll
These are my observations (of hospitalized patients):
1) Everybody is so swollen their skin has blisters and is so tight it looks like it's about to burst, from head to heel. And skin so dry peeling and flaky that to slather Vaseline on every shift is almost necessary - all over.

2) Everybody's skin is weeping clear fluid and has sores and the skin just slides off with slightest turn or rub, all over the body.

3) Everybody's blood is thick as slush. Can't figure out what's making it clot like that, but it's dark and thick.

4) Everybody's kidneys are failing. Urine dark or red, which could contribute to the swelling, but we don't know yet.

5) Everybody has an abnormal heart rhythm. Not sure of the cause. But even without underlying heart problems, it's not beating normally.

6) Seems counterproductive, but the ones that are not breathing on the ventilator have to lay flat on their stomachs to breathe better. And even some on the ventilator are on their stomachs. And the slightest turn for some is what leads to their almost immediate death. Bathing, cleaning and turning to prevent skin breakdown causes most to code blue, so a decision has to be made on which is most important.

7) Everyone has a Foley catheter and a rectal tube - incontinent of bowel and bladder.

8) Everybody on tube feeding. Everybody.

Never before in my entire career have I seen a disease process attack in this way.
- 20-year veteran nurse in NYC via Dr. Dee Knight

BSIP/Universal Images Group via Getty

I spent 10 days on a ventilator last March with ARDS [Acute Respiratory Distress Syndrome] and I'm still on oxygen. Going home is just the beginning of the next steps in recovering. Every aspect of my life has changed for the worse. Please support and help anyone you know who survived. And wear a mask!
- Nurse @liveV4Vendetta
I'm just getting over a "mild" case after over two months. There's scarring in my lower right lung and my stomach and digestion are a mess like never before. But I'm coughing way less and can take walks again.

And, btw, this is the third time in two months that I've "gotten better." I'm just hoping it's the last and it doesn't all come back AGAIN.

- Eli

I'm a nurse on a COVID floor, I caught it. I am a relatively healthy 24-year-old and could barely walk up a half flight of stairs. My blood pressure skyrocketed, chest pain was debilitating. I'm 8 weeks out and still feeling the chest pain and shortness of breath. This is no joke.
- Alicia
I had COVID for over 60 days. I'm 33 years old, was super healthy, pescatarian, 125 pounds, and ran and did yoga every day. I couldn't walk for two weeks besides a couple steps. It was the worst illness of my life.

I didn't realize I had COVID symptoms for weeks. Here were the early signs:

- Waking up sweaty (I normally don't sweat at night).

- Slight sporadic chills but no fever (or I thought I had no fever bc I only took my temp during the day).

- I could smell fine but would have weird smells like metallic or gas. Also, tasted metallic in the past 2-3 weeks. Apparently, a metallic taste or smell is related to lung problems.

- Loose stool but not terrible.

- Covid teacher (To read more about her symptoms and treatment, see her blog.)

I "recovered" March 29. I was born 65 years ago with chronic bronchitis that usually popped up maybe twice a year. Now, after COVID-19, I have acute bronchitis attacks 3-4 times a month and get winded walking to the mailbox.
- Hollis Charles

On right, lung of worlds first lung transplant for COVID- on left normal lungs
She is 20 pic.twitter.com/bwWvfdyIJt
- jeanne fisher (@jeannefisher17) June 15, 2020

I got COVID in March, and in May, developed symptoms of encephalomyelitis/chronic fatigue syndrome that leave me bedridden for days at a time. I'm so glad someone mentioned this so I know that I'm not the only one experiencing this.
- @PinkkYaYa
My mom worked on a COVID ward and contracted it, spent a month in ICU. She's lucky enough to be home now, but she struggles to get up stairs and it's going to be a long road to recovery. Thank you for everything that you do.
- Leanne
My coworker - an otherwise totally healthy 30-year-old - is still having issues breathing, two full months later. We've got patients coming back to the ER after they're "recovered" because they can't breathe or they get a blood clot. It's so insane.
- Andi
I had it back in March and did 6 days on a ventilator. To date, I'm still short of breath with little exertion. I have pains all over that I have never had before. I've noticed I don't urinate as much as I use to. And my legs & feet keep swelling so large no shoes fit. Even flops.
- Melly B.
I'm a healthy, active 23 year-old and I still have significant lung damage two months after I've "recovered."
- Laney Whitney
Yeah, my mom "recovered" mid-May, except she had *nothing* left. Couldn't even eat or drink, they wanted to surgically insert feeding tube into her stomach. I had to invoke her DNR instructions, that SUCKED. She passed May 25. Thanks for all you do, be safe, good luck.
- @DevinCojones

Worst sickness ever. Left me and my husband sick and weak for almost two months. Almost killed my perfectly healthy 41-year-old nephew. Took down a 36-year-old friend with two bouts of pneumonia. Wear a freaking mask, people. How hard is that?
-Padma's mom
My husband and I caught COVID two and a half months ago. While my symptoms were mild, he nearly had to be admitted because he couldn't breathe, and now, a month after he's recovered, we've discovered he has PERMANENT LUNG DAMAGE.

This is not "just the flu." It isn't.
- Sue Mii
I had a "mild" case in February. I wasn't hospitalized. Still extremely ill with a myriad of symptoms, including inflammation and lots of pain for 3 weeks. I have no doubt this virus causes permanent damage. Talk with someone who's had it before you decide to go without a mask.
- Leicia Faye MORE CORONAVIRUS COVERAGE: Sign up for 'The Daily' newsletter for the latest on coronavirus here. Mike Moffitt is an SFGATE Reporter. Email: moffitt@sfgate.com. Twitter: @Mike_at_SFGate

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What they don't tell you about surviving COVID-19

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Most people who catch the new coronavirus don't experience severe symptoms, and some have no symptoms at all. COVID-19 saves its worst for relatively few. ICU nurse Sherie Antoinette has seen the serious cases first hand. The lucky ones - if you can call them that - recover, but not in the sense that their lives are back to normal.

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KEY TAKEAWAYS

1. Close contact for extended periods of time

A major way that people contract Covid is through close-up, person-to-person interactions for extended periods of time, generally defined as 15 minutes or more of unprotected contact with someone less than six feet away. Bu that is only a rule of thumb. Scientists say it could take much less time with a sneeze in the face or other intimate contact where a lot of respiratory droplets are emitted.

2. Being indoors in loud, crowded, poorly ventilated areas

Crowded events, poorly ventilated areas and places where people are talking loudly also maximize the risk. Being outside is generally safer, experts say, because viral particles dilute more quickly. But small and large droplets pose a risk even outdoors when people are in close, prolonged contact.

3. Sneezes, loud talking, singing and heavy breathing

Similar transmission dynamics could be at play in other settings where heavy breathing and loud talking are common over extended periods, like gyms, musical or theater performances, conferences, weddings and birthday parties. When singing, people can emit many large and small respiratory particles. Singers also breathe deeply, increasing the chance they will inhale infectious particles.

4. Surface transmission is not as much of a risk

It's not common to contract Covid-19 from a contaminated surface, scientists say. High-touch surfaces like doorknobs are a risk, but the virus degrades quickly so other surfaces like cardboard boxes are less worrisome.

Read the original article by Daniela Hernandez, Sarah Toy and Betsy McKay here.

Copyright ©2020 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8

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How Do You Catch Covid-19? It's Becoming More Clear

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KEY TAKEAWAYS 1. Close contact for extended periods of time A major way that people contract Covid is through close-up, person-to-person interactions for extended periods of time, generally defined as 15 minutes or more of unprotected contact with someone less than six feet away. Bu that is only a rule of thumb.

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Just weeks after parts of the U.S. began reopening, coronavirus infections are on the upswing in several states, including Arizona, Utah, Texas and Florida. Dramatic increases in daily case counts have given rise to some unsettling questions: Is the U.S. at the start of a second wave? Have states reopened too soon? And have the recent widespread demonstrations against racial injustice inadvertently added fuel to the fire?

The short, unpleasant answer to the first question is that the U.S. has not even gotten through the current first wave of infections. Since peaking at around 31,000 average new daily cases on April 10, new daily cases dropped to around 22,000 on average by mid-May and have stayed almost steady over the last four weeks. Nationwide more than 800 people continue to die day after day.

Prominent forecasters are predicting a slow but steady accumulation of additional deaths between now and Oct. 1 - more than 56,000 by one estimate, around 90,000 by one another.

"We really never quite finished the first wave," says Dr. Ashish Jha, a professor of global health at Harvard University. "And it doesn't look like we are going to anytime soon."

That said, forecasters say, we could still be due for a true second wave later in the year, citing growing evidence that colder weather could lead to a surge in coronavirus cases.
Why we're stuck
So why is the U.S. stuck in a coronavirus plateau despite months of widespread social distancing? To explain, it helps to get a bit technical. The key indicator at issue is what's called the "reproduction number" of the coronavirus - or the R for short - essentially a proxy for how powerfully infection is spreading in your community. It tells you, for each individual who is infected, how many other people this person will go on to infect. When the reproduction number is above 1, case counts will spiral upward exponentially. When it gets to well below 1 and stays there, outbreaks subside.

For example, if the reproduction number is 2, then one person goes on to infect two others. Those two people go on to infect four others. Those four go on to infect eight, then 16 and so on. If you assume, say, a six-day interval between each new round of infections - in just over a month, that one initial person will have launched a chain that has infected 127 people.

Most estimates are that early this year, when no measures were being taken to keep the coronavirus in check, the reproduction number in the U.S. was above 2.

The stay-at-home measures and other social distancing efforts that states undertook this spring served to push the reproduction number to slightly below 1 - to 0.91, according to an estimate by Youyang Gu, an independent modeler whose work is highly regarded by prominent epidemiologists.

This halted the upward spiral of cases. But because the reproduction number was still so close to 1, the curve of new infections never really bent sharply downward. Essentially most of the U.S. reached a kind of steady state - with each infected person passing the virus on to one new person in a regular drip-drip of new infections and new deaths.

Now that states have opened up, the reproduction number has started to creep back up above 1. According to Gu's analysis, that is now the case in more than two-thirds of the states.

So far, at least, the reproduction number has been hovering at just above 1. Assuming that remains the case, the U.S. won't see the kind of runaway run-up in cases that was so alarming in New York. But it does mean cases and deaths will continue to accrue steadily.

"If things stay basically status quo and we continue doing what we're doing, we're going to continue seeing 25,000 to 30,000 additional deaths a month for the foreseeable future," Jha says.

Grim as it is, even this picture may be overly rosy, Jha adds. "I'm worried that the idea that we're going to stay flat all summer is a very optimistic view of what is going to happen over the next three months," he says.

To maintain a reproduction number that's just over 1, or better yet, push it back to just under 1, even in the midst of further re-opening "would take a lot of work," Jha says. "You'd have to have really substantially ramped-up testing and isolation [of new cases]." There's also evidence emerging that widespread use of masks by people when they are out in public could help, Jha notes. Unfortunately, he says, it is hard to envision the U.S. adopting any of these practices to a sufficient degree "based on where we are today."
The seasonal effect
It gets worse. On Thursday, Chris Murray, the head of the University of Washington's Institute for Health Metrics and Evaluation forecasting team, pointed to growing evidence that the coronavirus will spread more easily as the weather turns cold.

Murray's team analyzed the pattern of the spread of the coronavirus in the U.S. to date. They found that the drop in the reproduction number since early spring can't be entirely explained by obvious contributing factors - such as people's reduced mobility or mask wearing or better testing. And when the team looked for additional variables that could explain the change, it found a strong correlation with warming weather.

This finding doesn't shed light on why transmission may be reduced in the warmer months. (For example, could it be that coronavirus droplets don't hang in warmer air for as long? Is it simply that people spend less time mingling with each other indoors?) But Murray says that "as time goes by, the evidence is accumulating that it is a very strong predictor of transmission."

The effect is not strong enough to make the virus completely disappear over the summer. But it does mean, Murray says, that come autumn transmission will likely pick up.

"We start to see a powerful increase that will be driven by seasonality starting in early September and these numbers will intensify through till February," Murray says. "So seasonality will be a very big driver of the second wave."

He adds though, that this does not take into account actions that could mitigate the impact. "Clearly what individuals choose to do can moderate the forecast," he says, noting that widespread mask use and avoidance of social contact with people outside one's household could help.
Parsing the effects of protests
Even as many public health experts cheered the anti-racism protests - and the possibility that lives could ultimately be saved if demonstrations result in policy changes that reduce racial inequities - some wondered at the extent to which these would come at a cost of increased deaths from COVID-19.

But calculating just how many additional deaths the demonstrations might lead to is difficult. There is no accurate count available of the number of participants, let alone their ages - which appear to skew young, suggesting the vast majority of those infected would not experience bad outcomes.

Also with little prior research on this particular form of intermingling, it's hard to say how much infection results from it. Though many people have been standing and marching in close quarters, being outdoors mitigates the effect of crowding, as does mask use.

But the biggest determinant of how many deaths ultimately result is what happens in the aftermath of the demonstrations, says Marc Lipsitch, an epidemiologist at Harvard.

"Some transmissions will almost certainly happen at the protests and the question is whether those lead to a lot of cases down the line or a relatively small number of cases down the line," he explains. Do those who are infected at marches go back into an environment where there's a high level of ongoing transmission or a low level?

"How much transmission happens later on," Lipsitch adds, "is far more dependent on our actions as a society and whether we can suppress transmission around the country than on how many people go to the protests."

In other words, perhaps the better question is not, will the demonstrators cause a spike in COVID-19 infections? But rather will all of us - the public and our leaders - behave in a way that keeps the reproduction number low and ensures that these marches and any improvements to racial equality they achieve don't come at a price of many more COVID-19 deaths.

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Coronavirus 2nd Wave? Nope, The U.S. Is Still Stuck In The 1st One

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Just weeks after parts of the U.S. began reopening, coronavirus infections are on the upswing in several states, including Arizona, Utah, Texas and Florida. Dramatic increases in daily case counts have given rise to some unsettling questions: Is the U.S. at the start of a second wave? Have states reopened too soon?

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Although we do not yet know the effect of more recent events on the course of the pandemic, or what exactly will happen in the coming weeks and months, the list of culprits will likely be even longer than that.

If the virus wins, it may also be because Derek Chauvin kept his knee on George Floyd's neck for eight minutes and 46 seconds as Floyd was pleading for his life, setting off protests that-as righteous as they are-could well result in mass infections.

If the virus wins, it may also be because 1,200 public-health experts obfuscated the mortal risk that these mass protests would pose to the most vulnerable among us by declaring not only (as would be reasonable) that they supported them as citizens, but also (which is highly implausible) that they had determined, as scientists, that they would actively serve "the national public health."

If the virus wins, it may also be because so many states moved to reopen before getting the pace of infections under control.

If the virus wins, it may also be because the right-wing-media echo chamber is starting to downplay the risk that a second wave poses to Americans.

If the virus does win, then, it is because American elites, experts, and institutions have fallen short-and continue to fall short-of the grave responsibility with which they are entrusted in ways too innumerable to list.

About a month ago, I started to write a very different article. "Is it possible," I wondered, "that with the benefit of hindsight, this cruel period will seem rather more heroic than is obvious to its contemporaries? One thing is clear: If we had let the virus rip through the population unchecked, the consequences would have been unspeakable. But if-a big if-we manage to contain the pandemic, and avert millions of deaths, it would constitute one of the greatest achievements in human history."

Hoping to publish the article in The Atlantic, I kept waiting for the situation in the United States to recover sufficiently to justify my guarded optimism. But that moment never arrived. Now it feels more remote than ever.
Read: America's patchwork pandemic is fraying even further
We were on the brink of doing something incredible. And much of the credit for that would have gone to the many ordinary citizens who lived up to their moral responsibility in an extraordinary moment.

Scientists have desperately searched for a vaccine. Despite the real risks to their health, doctors, nurses, cooks, cleaners, and clerical staff have reported for duty in their hospitals. Suddenly declared "essential," workers who have long enjoyed little respect and low wages helped to keep society afloat.

For the rest of us, the order of the day was simply to stay at home and slow the spread. It was a modest task, which made it all the more galling that some people fell short. But this nitpick obscures how many people did do what they could to get us all through the crisis: They checked in with their relatives and cooked for the elderly. They took to their balconies to thank health-care workers or sang songs to cheer up the neighbors. By and large, they stayed at home and slowed the spread.

Thanks to the effort of millions of people, we were close to a great success story. But because of the failures of Trump and Chauvin, of the CDC and the WHO, of public-health experts and Fox News hosts, we are, instead, likely to give up-and tolerate that hundreds of thousands of our fellow citizens will die needless deaths.

Pandemics reveal the true state of a society. Ours has come up badly wanting.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

Yascha Mounk is a contributing writer at The Atlantic, an associate professor at Johns Hopkins University, a senior fellow at the German Marshall Fund, and a senior adviser at Protect Democracy. He is the author of The People vs. Democracy.

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incompetence of the trump administration

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Although we do not yet know the effect of more recent events on the course of the pandemic, or what exactly will happen in the coming weeks and months, the list of culprits will likely be even longer than that.

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Is It Safe to See Friends Now That Lockdowns Are Lifting? Here's What Experts Say

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Is It Safe to See Friends Now That Lockdowns Are Lifting? Here's What Experts Say

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Is It Safe to See Friends Now That Lockdowns Are Lifting? Here's What Experts Say

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So your state is allowing group gatherings again. Is it risky to take part?

With stay-at-home orders being lifted in states across the country this month, many of us are wondering, is it actually safe to see family and friends in person right now? And if so, what precautions should we take?

The guidelines about socializing vary by state. Some states, like Louisiana and Massachusetts, have no restrictions on the size of gatherings. In New York and Illinois, groups of up to 10 people are allowed, while New Jersey permits indoor gatherings of up to 10 people and outdoor gatherings of up to 25 people. In California, gatherings of any number of people who are not members of your household are still prohibited.

Meanwhile, the Centers for Disease Control and Prevention (CDC) continues to advise against socializing in groups and recommends avoiding crowded places and mass gatherings-such as conferences, festivals, parades, concerts, sporting events, and weddings. That's because many people with COVID-19 are asymptomatic yet can still spread the virus. According to the World Health Organization (WHO), 80% of infections are mild or asymptomatic. "Recent studies indicate that people who are infected but do not have symptoms likely also play a role in the spread of COVID-19," states the CDC.

That may have happened a few weeks ago at a party in Arkansas. CNN reported that an asymptomatic person attending a Memorial Day party at the Lake of the Ozarks tested positive for COVID-19. He also visited several bars and restaurants. Over the course of a few hours, he put everyone at the party and anyone else he was in close proximity to at risk of becoming infected.

So if you live in an area where socializing is legally permitted and you want to start seeing friends, how can you do it safely? The answer isn't the same for everyone, says David Cutler, MD, family medicine physician at Providence Saint John's Health Center in Santa Monica, California. "Your ability to socialize safely depends on three factors: the risk of the activity you're engaging in, your risk of death from COVID-19, and the safety measures you employ when socializing," he tells Health. Before you arrange that catchup, here are four things to bear in mind.

There's a "risk spectrum" when it comes to socializing

Some gatherings, like a large party in a small house, pose more danger of transmission than others, such as inviting a friend for a drink on your front porch. So if you're dying to socialize, do it in intimate groups and ideally outdoors, where fresh air between people drives down the risk.

"A visit of a few people for an hour or two on your patio with social distancing in place and masks puts you at less risk than spending the day with friends attending a birthday swim party, with large numbers, close proximity, and no masks," Carol A. Winner, MPH, founder of the Give Space movement and director of federally funded community health-based initiatives, tells Health.

If you want to have a friend to visit you in your home-and there's no local order in place to prohibit this-that's absolutely fine. But Winner believes it's wise to keep your home "a safe haven" and recommends holding visits in your yard, on top of maintaining social distance and wearing masks. If this isn't possible, she recommends choosing a place where there are no crowds and social distancing is being maintained-again, preferably outside.

If you're hosting a small outside gathering, take the necessary time to prepare. "Wipe down your chairs and tables and spread the seating apart so everyone can have a safe space," says Winner, ideally at least six feet from the next person. "Serve any food on paper plates, with disposable bottles or throw-away paper glasses and utensils for a safe cleanup afterwards." Make sure people know to only remove their masks when they are eating.

It's also smart to limit your gatherings to eating, drinking, and sharing conversation-from a safe distance, of course. "Save the game-playing for another time, or schedule one on Zoom for later," suggests Winner. Game-playing puts you and your guests at risk of transmitting virus via your hands or on surfaces like cards or a game board.

Decide who you want in your "COVID bubble"

Staying safe means trying your hardest to follow all coronavirus health and safety recommendations. But that can be difficult if the friends and family members you want to hang out with again aren't doing the same...especially if their lax behavior starts to rub off on you.

"When we see people around us without masks or not adhering to social distancing guidelines, we think, Maybe I don't need to worry so much anymore. It is a false sense of security," says Winner. "The numbers of new cases and deaths tell us of the dangers and that healthy behaviors need to continue to survive the virulence of this virus. We must continue to be extremely cautious."

This is where the idea of a "COVID bubble" comes into play. Think of it as a group of people you know well enough to trust that they've been following all the safety guidelines. So when you do get together, you can be reasonably sure you're safe. Your COVID bubble can be as large as you want it to be-it's a wider social circle made up of people that you feel safe socializing with during the pandemic. (But depending on the size, not necessarily all at once.)

Before deciding who is in your bubble, ask yourself: Have they been staying at home? Have they been practicing social distancing when they've been out of the home? Have they attended any large events? Are they going to work? Have they been wearing a mask? Spending time with someone who hasn't been following the guidelines for the last two months could quickly undo all the safety measures you've taken to protect yourself and your household.

Consider the dangers to friends and people in your household

Before you catch up IL with friends and family, Winner says it's important to consider the risk not only to yourself but to those in your household as well as those you're thinking of seeing again. If you or any of those people are elderly or have an underlying health condition, it's sensible to wait. They are more susceptible to contracting the virus and are also more likely to have a harder time fighting it off-and you don't want your social gathering to be the place they inadvertently became infected.

"Any person who is older, and especially those with high-risk medical conditions like obesity, lung disease, heart disease, hypertension, or diabetes, should continue to restrict their social activity where there is significant risk of acquiring COVID-19," says Dr. Cutler. "Those in middle age, or younger people with a medical condition, may want to take some measures to reduce risk, while young healthy people can be less concerned about the risk to them." If you've been staying home, making hygiene a priority, and following social-distancing measures, Dr. Cutler says your likelihood of having COVID-19 is very low.

If you're not sure about your risk level, or have concerns about a particular social activity, Dr. Cutler advises speaking to your primary-care physician. "They have the best understanding of your medical risk and are also familiar with public-health recommendations, both nationally and in your area," he says.

Are our days of spontaneous socializing over? No-but it may be a long time before we go back to it. "Once we have consistent quality and adequate testing procedures and contact tracing to be able to isolate active cases, our risk will be lower and we will have more freedom," says Winner. Until that point, it's crucial to stick to healthy behaviors-hand-washing, social distancing, and wearing masks-that have become part of our daily routines. We all want to visit our friends again, but it's more important to keep them safe.
The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the To get our top stories delivered to your inbox, sign up for the Healthy Living newsletter CDC, WHO, and their local public health department as resources.

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Is It Risky to Hang Out With My Friends Now That Lockdowns Are Lifting? We Asked Experts

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So your state is allowing group gatherings again. Is it risky to take part? With stay-at-home orders being lifted in states across the country this month, many of us are wondering, is it actually safe to see family and friends in person right now? And if so, what precautions should we take?

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The pandemic has exposed the bitter terms of our racial contract, which deems certain lives of greater value than others.

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The pandemic has exposed the bitter terms of our racial contract, which deems certain lives of greater value than others.

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The Atlantic
ADAM SERWER
MAY 8, 2020

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The Coronavirus Was an Emergency Until Trump Found Out Who Was Dying

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The pandemic has exposed the bitter terms of our racial contract, which deems certain lives of greater value than others.

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Coronavirus may never go away, even with a vaccine

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Coronavirus may never go away, even with a vaccine

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Embracing that reality is crucial to the next phase of America’s pandemic response, experts say.
The Washington Post
By William Wan and Carolyn Y. Johnson

May 27, 2020

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Is There Any Safe Way to Socialize During the Coronavirus Pandemic?

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Is There Any Safe Way to Socialize During the Coronavirus Pandemic?

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TIME
BY JAMIE DUCHARME

MAY 19, 2020
"Given all those risks and unknowns, "the most responsible option is to have [a social] visit virtually,” says Brandon Brown, an epidemiologist and associate professor in the Center for Healthy Communities at the University of California, Riverside. That will be the case until there’s a vaccine to confer widespread immunity, as well as better testing capacity and steady declines in deaths and cases to decrease the burden on the health care system, Brown says."

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Is There Any Safe Way to Socialize During the Coronavirus Pandemic?

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Social-distancing guidelines limit socializing during the COVID-19 pandemic. But is there any way to see a loved one safely?

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Coronavirus ‘silent spreaders’ become a bigger risk as California reopens

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Coronavirus ‘silent spreaders’ become a bigger risk as California reopens

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The role of "silent spreaders" in transmitting the coronavirus is becoming an even greater issue for health officials as they ease stay-at-home rules and slowly reopen the economy.

Health officials have stressed the importance of creating an army of disease detectives - investigators who can interview newly infected people and find their close contacts, telling them to quarantine themselves for 14 days in hopes of keeping other people from getting infected.

But if many people who get the virus don't show symptoms and yet are infectious, the disease could spread invisibly, beyond the reach of county health officials.

Health experts say it can take a few days from the time a person becomes infected, and could infect others, and the point at which they begin to show signs of illness. It's called "presymptomatic transmission." There's also "asymptomatic transmission," in which infected people show no serious signs of illness but still can spread the disease.

There's increasing concern that silent spreaders are playing a large role in the transmission of COVID-19, which is becoming the greatest public health threat of the century. With a possible new surge in coronavirus cases in the fall, being able to find those people becomes more crucial.

Identifying silent spreaders also is important as California eases stay-at-home rules now, allowing people to eat inside restaurants, shop in stores, go to beaches and parks, and resume in-person church services.

All these activities come with strict social distancing rules designed to make it harder to spread the virus. But scientists and officials say that reopening brings new risks, especially when people who have the illness but show no symptoms are out and about.

The U.S. Centers for Disease Control and Prevention estimates there's a 20%-to-50% chance that those infected with the coronavirus do not show symptoms. Yet even those asymptomatic people may be just as capable of transmitting the disease as other infected people who eventually become visibly sick, the CDC said.

That's why it's so important to adhere to social distancing and wearing masks, experts say.

"The best way to protect yourself - and to protect others in case you yourself were infected - is to treat it as though everyone is potentially infected," said Dr. Robert Kim-Farley, medical epidemiologist and infectious disease expert at the UCLA Fielding School of Public Health. "Keep that social distancing. And keep that masking on."

Kim-Farley said images of large numbers of people gathering closely together without masks is going to result in increased spread of the coronavirus. It can take two to four weeks before an accelerating rate of infections can be observed in worsening hospitalization numbers and a rising weekly death toll.

"Without having social distancing, we are going to definitely see some increased spikes and transmission occurring. That's definitely going to happen," said Kim-Farley, a former senior official with the L.A. County Department of Public Health, the CDC and World Health Organization.

Federal officials have echoed those warnings.

"We've made it clear that there's asymptomatic spread, and that means that people are spreading the virus unknowingly. And this is unusual in the case of respiratory diseases ... so you don't know who's infected," Dr. Deborah Birx, the White House's coronavirus response coordinator, told ABC News on Sunday.

Of 402 residents and workers testing positive for the coronavirus at Los Angeles County nursing homes, 345 of them had no symptoms of illness, the director of public health, Barbara Ferrer, said last week. In other words, 86% of people testing positive at scores of skilled nursing facilities across the nation's most populous counties had no symptoms of the disease when they were tested.

This is not the only study to raise concerns about the large numbers of presymptomatic or asymptomatic infected people. A UC San Francisco study conducted in late April found that, among several thousand residents and workers in San Francisco's Mission District, 62 people tested positive for COVID-19 - but more than half of them, 53%, had no symptoms at the time they were tested.

An editorial in the New England Journal of Medicine in late April called asymptomatic transmission of the coronavirus "the Achilles' heel of COVID-19 pandemic control through the public health strategies we have currently deployed."

"Live coronavirus," the editorial said, "clearly sheds at high concentrations from the nasal cavity even before symptom development."

In another , also published in the New England Journal of Medicine, 56% of residents at a skilled nursing facility in Washington state's King County who initially tested positive in a survey of patients showed no symptoms at the time, but most later did show signs of illness. It took a median of four days for them to show symptoms.

Visibly healthy people can also be omitted from other efforts aimed at trying to identify infected people, such as attempting to screen incoming airline passengers from overseas countries.

And a silent spreader can transmit the coronavirus simply by talking. Loud talking can emit thousands of saliva droplets per second, and researchers recently found that, in a stagnant air environment, droplets of fluid sprayed from the mouth remained in the air for as long as eight to 14 minutes before drying up.

"These observations confirm that there is a substantial probability that normal speaking causes airborne virus transmission in confined environments," said the authors in the study published in the Proceedings of the National Academy of Sciences on May 13.

Pre-symptomatic people have been identified as the index patient in a number of outbreaks.

In the southern Chinese city of Guangzhou, one person who had just returned from Wuhan - the epicenter of the global pandemic - was pre-symptomatic while eating lunch on Jan. 24 at a restaurant with family. Scientists concluded that person infected two other families sitting at neighboring tables about three feet away, according to a report published by the CDC. Scientists suspect that infected droplets from the index patient hitched a ride on air flows powered by an air-conditioning system.

In Singapore, pre-symptomatic tourists from Wuhan visited a church in Singapore on Jan. 19 and started showing symptoms several days later. Three other people who attended the same church on the same day also got sick, including one who sat in the same seat as the tourists, according to closed-circuit camera video documented in a CDC report. Officials did not uncover any symptomatic church attendees who visited that day.

It's easier to suffocate a disease where the symptoms are obvious, and in which infectiousness occurs after symptoms show up, Kim-Farley said. For instance, there are very few asymptomatic cases of measles, and officials can identify cases, isolate them, find the infected person's close contacts and quarantine them, snuffing out an outbreak.

But diseases where there's a large share of asymptomatic cases can be far harder to deal with. For instance, for every 100 people who were infected with polio, only about one person fell ill with paralysis, Kim-Farley said. "So it's highly asymptomatic. So that's why you really can't do contact tracing for polio, because for every case that you identify that has symptoms, there are 99 others that don't. So it's silently spread in the community."

That's why, in the years before the polio vaccine was available on a large scale in the mid-1950s, many parents kept their children at home, even in the summer when the spread of the virus seemed to peak. Polio was once one of the nation's most feared diseases, more than 35,000 people a year, on average.

There are some estimates that suggest the proportion of asymptomatic patients may be even higher than what the CDC has said publicly: Experts estimate that 25% to 75% of coronavirus infections may be asymptomatic, Kim-Farley said. If it's on the higher end, even public health officials with robust disease-detective resources could fail to detect much of the spread of the disease

In such a situation, health officials should take aggressive measures to protect the most vulnerable, like those in nursing homes, until the number of new cases falls to essentially zero, Kim-Farley said.

Silent spread of the coronavirus is all the more reason to wear masks in public, Dr. George Rutherford, an epidemiology and infectious-disease expert at UC San Francisco, said Thursday in a campus webinar.

"What we're really trying to do is prevent transmission from talking," Rutherford said. "We're trying to ... prevent people who are asymptomatically infected from transmitting."

America learned the lesson of wearing masks a century earlier. In an unearthed photo showing fans at a Georgia Tech football game during the 1918 flu pandemic, most people are wearing masks.

"As you can see, everybody in the stands has on masks. So that's what's gonna help us out," Rutherford said.

Face coverings not only help keep asymptomatic people from transmitting the virus to others, he said, but they also provide some protection to the wearer.

The White House's Birx has emphasized the importance of masks, saying on ABC News, "Social distancing is absolutely critical. And if you can't social distance and you're outside, you must wear a mask. These are items that are really critical to protect individuals."

She said it would also be important to proactively test asymptomatic people, such as residents and workers at nursing homes and workers at meatpacking plants and in agriculture. The coronavirus can spread rapidly in the right conditions.

"What I'm worried about is: What are we putting in place to find asymptomatic cases?" Birx said. "All of this proactive testing needs to be in place - and needs to continue to be in place - because that will determine safely remaining open in the fall."

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Coronavirus 'silent spreaders' become a bigger risk as California reopens

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The role of "silent spreaders" in transmitting the coronavirus is becoming an even greater issue for health officials as they ease stay-at-home rules and slowly reopen the economy. Health officials have stressed the importance of creating an army of disease detectives - investigators who can interview newly infected people and find their close contacts, telling them to quarantine themselves for 14 days in hopes of keeping other people from getting infected.

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Opinion: The Quarantine Bubbles Are Coming and I, for One, Am Stressed

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Opinion: The Quarantine Bubbles Are Coming and I, for One, Am Stressed

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How do you decide who belongs in yours? What if you join and find it’s not working out? And what if you aren’t invited to one at all?

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How do you decide who belongs in yours? What if you join and find it's not working out? And what if you aren't invited to one at all?

By

Contributing Opinion Writer

How will we decide who belongs in our quarantine bubble? Credit... Sean De Burca/The Image Bank, via Getty Images

Truly, the coronavirus is a gift that keeps on giving.

First, it gave us the fear that we, or a vulnerable loved one, might contract a horrifically contagious disease and die a painful death in an overcrowded, underequipped hospital.

Then there was the stress of quarantine. Marriages have been strained, the bonds of familial love stretched to the breaking point. Even people who love each other were not meant to spend every hour of every day together, which is why God invented schools, workplaces, gyms, bookstores, coffee shops, poker games and those wine-and-paint places where you come home tipsy, toting a picture of a daisy in a vase.

There's been the economic devastation: businesses shuttered, employees fired and laid off and furloughed. There's been the politicization of a period where all Americans should be pulling together, and social media, which has force-fed us images of crowded beaches over and over, sparking new outrage with each viewing.

And now, on top of all this, here comes the social anxiety. Here come the quarantine bubbles.

A quarantine bubble is a group of individuals or families whose members have been safely quarantining and who can now start hanging out with other observant groups, so long as the families observe safety guidelines and agree to be exclusive.

That's the next step some European countries are choosing as they start to ease their lockdowns. Last month, First Minister Nicola Sturgeon of Scotland said that some countries are looking at "slightly expanding what people would define as their household - encouraging people who live alone to maybe match up with somebody else who is on their own or a couple of other people to have almost kind of bubbles of people."

In Belgium, the government is allowing quarantining citizens to invite up to four guests into their homes and to travel to their guests' house. "Two sets of four people make a 'corona bubble,' who can visit each other's homes. No one else is allowed into the domestic social circle," The Guardian wrote, adding, with typical English understatement, "the concept, also being discussed by the British government, opens up the biggest social minefield of the coronavirus lockdown." You don't say.

Because what if no one picks you for their bubble? And how do you decide who belongs in yours? How do you issue an invitation, or reject one? What if your parents swear they've been following the rules and are dying to see their grandchildren, but you're not ready to risk it because they're Fox News viewers and who the hell knows what they think "observant" even means? What if you're desperate to hang out with your bestie, but she's already committed to a guy she met three weeks ago on a dating app and wants to get to know in person? And again: What if no one picks you?

It's true that bubbling could provide an exit strategy for those friendships that have been running on fumes - the college buddy who won't stop talking about microbrewing or needle felting, the former bridesmaid who's gotten religion or a Peloton bike. Sorry not sorry, but because of the virus, I won't be able to see you for a while. It's not you, it's Covid.

But the idea of bubbling could also ignite every simmering insecurity in your possession. If the very thought of being picked last or going completely, utterly unchosen is giving you flashbacks to junior high where Michelle Goldman said that you couldn't sit at her table in the cafeteria because all the seats were taken when clearly all the seats were not taken, I am right there with you. And would like to remind you that you are a successful, accomplished, beloved adult and also how many novels has Michelle published?

I digress.

But then, once you've cleared that first hurdle and gotten yourself bubbled, what are the rules? Are you obligated to hang out every time your chosen four want to? How do you agree on what's reasonable versus risky? And if your puzzle just isn't clicking - if it turns out that you're just not that into them or they're just not that into you - how do you break up the bubble and start seeing other people?

My prediction? To quote Clubber Lang in "Rocky 3": "Pain."

So I asked Irene S. Levine, psychologist, friendship expert and author of "Best Friends Forever: Surviving a Break-Up With Your Best Friend," for advice.

Her first tip: Do a risk/benefit analysis. Before embarking on the bubble experiment, be sure that you really, really need to be seeing other people. Make a considered decision before inviting trouble, and possibly infection.

"Some people need to affiliate more than others," Dr. Levine said.

If you get rejected, try not to take it personally - or at least, tell yourself that there might be other reasons, from pre-existing conditions to prior obligations, to explain why you didn't get the bubble tap.

If you have to reject someone, don't lie, don't be coy, and don't, for God's sake, put pictures of the winning friends or relatives on social media until you've spoken to the unchosen ones, and maybe not even after. Bad enough you're going to reject your own mother in favor of your mother-in-law. Don't make Mom watch it play out on Facebook.

Once your bubble begins, as with any relationship, communication is key, Dr. Levine said: "You'll want to develop a social contract with the other family. Agree on the rules. Discuss your attitude toward risks and the way you go about your lives. Figure out what to do if someone breaks the rules" - because as awkward as it might be to talk it through before things go sideways, it will be that much worse if you wait until that's happened to figure out what to do.

Finally, understand that it's temporary. Whether you're the rejecter or the rejectee, there's always the possibility that things can expand later, which should help to soothe you, or the rejected parties. "This isn't forever," Dr. Levine said.

Of course, the pandemic isn't, either - it's just starting to feel that way. And if nothing else, the bubble experiment could be useful in reshuffling your anxieties as the weeks melt into months. If you've run out of things to read, and watch, and bake, the prospect of a bubble can give you something new to look forward to - or obsessively worry about.

You're welcome.

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Opinion | The Quarantine Bubbles Are Coming and I, for One, Am Stressed

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How do you decide who belongs in yours? What if you join and find it's not working out? And what if you aren't invited to one at all? By Contributing Opinion Writer Truly, the coronavirus is a gift that keeps on giving.

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6 feet away isn’t enough. COVID-19 risk involves other dimensions, too.

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6 feet away isn’t enough. COVID-19 risk involves other dimensions, too.

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Distance, time, activity, environment: 4 ways to think about COVID-19 risk as states reopen.

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When states had strict stay-at-home orders and lockdowns in place, many decisions about the risk of getting the coronavirus were simple. People didn't have to think about whether dining in a restaurant is safe if the restaurant was closed.

Now, that states are opening up - with varying degrees of precautions and adherence in place - individuals will need to weigh some risks on their own.

It isn't easy; information about what's safe, and what's not, can be contradictory and confusing. A state may allow restaurants to reopen and concerts to resume, but should you really go? Is it safer if people are only allowed to dine outside?

The hunger for guidance is clear: On May 6, infectious disease expert Erin Bromage posted a blog post summarizing the evidence of coronavirus transmission risks, and 17 million people have since read it, he says. The CDC didn't post its own updated guidance for individuals and events venturing out into a post-lockdown world until June 12. Perhaps a bit too late, as new cases and hospitalizations are currently rising in several states.

As Bromage conveys, the scientific understanding of how the virus transmits in public is improving. Contact tracing studies around the world have taken a magnifying glass to the "superspreading" events, where one person ends up infecting dozens of others. These studies shine a light on the key risk factors that create dangerous situations.

From these studies, one thing is clear: The main way people are getting sick with SARS-CoV-2 is from respiratory droplets spreading between people in close quarters. The risk of catching the coronavirus, simply put, "is breathing in everybody's breath," says Charles Haas, an environmental engineer at Drexel University. Droplets fly from people's mouths and noses when they breathe, talk, or sneeze. Other people can breathe them in. That's the main risk, and that's why face masks are an essential precaution (they help stop the droplets from spewing far from a person's mouth or nose).

The Centers for Disease Control and Prevention (CDC) emphasizes the risk of close contact over other modes of transmission. "The virus does not spread easily in other ways," the CDC writes. It's still possible that a person can catch it from touching a contaminated surface (more on that below.). But it's "not thought to be the main way the virus spreads," the CDC states.

As Bromage put it in his piece, "We know most people get infected in their own home," from housemates or family members who caught the virus in the community.

So how can we assess the risk of going places outside the home?

The story is a little more complicated than the simple "stay 6 feet away" guidelines. Coronavirus risk is simply not one-dimensional. We need to think about risk in four dimensions: distance to other people, environment, activity, and time spent together.

Let's walk through them.

A simple suggestion: Imagine people are smoking, or farting really bad, and try to avoid breathing it in

It's easy to get into the weeds talking about the risk of catching and spreading the coronavirus as people reenter communal spaces in society. We can talk about the number of viral-laden droplets expelled by a single breath ( a lot, perhaps 100 or more), by a person talking ( 10 times more than breathing), about how far a sneeze can propel those droplets ( much farther than 6 feet), how long those viral droplets linger in the air (around eight to 14 minutes, at least in a controlled indoor lab setting).

But really, what all this means is that the greatest Covid-19 risk is being around breathing, laughing, coughing, sneezing, talking, people.

It's still hard to visualize the risk, though, as the respiratory droplets are invisible to our eyes.

Perhaps helpful: Imagine everyone is smoking, as Ed Yong reported in the Atlantic, and you'd like to avoid inhaling as much smoke as possible. In a cramped indoor space, that smoke is going to get dense and heavy fast. If the windows are open, some of that smoke will blow away. If fewer people are in the space, less smoke will accumulate, and it might not waft over to you if you're standing far enough away. But spend a lot of time in an enclosed space with those people, and the smoke grows denser.

The denser the smoke, the more likely it is to affect you. It's the same with this virus: The more of it you inhale, the more likely you are to get sick.

An alternative image to thinking about this risk: "With my kids, I just sort of joke around that if you can smell their farts, you need to move farther apart," Bromage says. So if not smoking, imagine everyone is farting. Keep this in mind and surely you'll realize outdoor activities are better than indoor ones. "This tells you the gradient of risk," Bromage says. "The closer you are, the more it's gonna smell, the more dangerous it is."

At a barbecue, you can still imagine being close enough to people to smell their farts. So even in outdoor spaces, we need to limit our contacts.

A crowded indoor place, then, with poor ventilation, filled with people talking, shouting, or singing for hours on end will be the riskiest scenario. A sparsely populated indoor space with open windows is less risky (but not completely safe). Running quickly past another jogger outside is on the other end of the spectrum; minimal risk.

There are many scenarios in between. "In general, outdoors is lower risk," Muge Cevik, a physician and virology expert at the University of St. Andrews, says. But "if you have a gathering or a barbecue outside, and you spent all day together with your friends, your risk is still higher."

What recent contact tracing studies can teach us about risk

Scientists pointed out a few recent contact tracing studies that nicely illustrate the dimensions of Covid-19 risk.

In China, 8,437 shoppers and employees of a supermarket were tracked in late January after one of the employees was confirmed positive with Covid-19 while working in the store.

The risk for infection was much higher for the workers than for the shoppers. Around 9 percent of the supermarket employees (11 out of 120 employees) got sick as a result. But just 0.02 percent of the shoppers (2 out of 8,224 shoppers) got sick.

What does this show?

The employees are at a much larger risk due to the time they spent working in the store. Both the employees and shoppers were in the same physical space, but their risk was not the same. (The study did not note whether the shoppers and customers were wearing masks in the store.) The employees may have interacted more with their colleagues, but they also had a greater chance of breathing in the virus.

What we should learn from this: If we have to spend time with people indoors, try to make it quick.

Another recent study out of China investigated an outbreak that started at a Buddhist temple event.

Two buses brought people to the function. On one of the buses, there was a person who later tested positive for the coronavirus who had not yet started to feel symptoms. The other bus was free of infected people.

Both buses brought people to the same temple, where they mixed and mingled outdoors*. But who was most at risk of getting sick? Those who rode the bus with the infected person. Twenty-four out of 67 people on that bus got sick. No one on the other bus did. The event was attended by another 172 people who arrived by other transportation. Only seven of these people got sick.

The lesson? The confines of a bus are a much riskier environment for viral spread than a larger outdoor space, like at the temple. The risk at the temple was not zero. But it was much reduced compared to the confines of the bus. And it appears those who were exposed at the temple were in close contact with the infected person.

"When you look at public transport, work spaces, restaurants - places where we're just trying to fit many people in a small confined space - respiratory viruses like those spaces," Cevik says. It's "just common sense."

There's no set time that's safe to be in these places. "Generally, for droplet transmission, we say 15 minutes," Cevik says. "So if you spend 15 minutes face to face with somebody, you're close contact [and at high risk], but that doesn't mean if you spend 14 minutes your risk is zero." And if you have to choose between a big open indoor space and a smaller one, choose the larger one, where people can spread out.

It's not just the location or the time spent together: The activity people are engaged in matters, too.

In Washington state, a person with the virus attended a choir practice, and more than half of the other singers subsequently got sick. This was labeled a "superspreading" event, as one infection led to 32 others. Why was this so risky?

"The superspreading event is about the behavior of the person involved," Cevik says. There are many reasons why a person could become a "superspreader": Some people shed more of the virus than others, and it appears people shed most of it when they are just starting to feel symptoms.

But what made this event so risky was the convergence of many risk factors: the singing activity (during which the infected person released viral particles into the air), the time spent together (the practice was 2.5 hours), and the interaction between the choir members in an enclosed space (not only did they all practice together, they also split up into smaller groups and shared cookies and tea).

In a new paper published by CDC, researchers in Japan identified 61 clusters (five or more cases stemming from a common event) of Covid-19 cases. The researchers found most commonly the clusters originated in health care facilities. But outside of that they note "many Covid-19 clusters were associated with heavy breathing in close proximity, such as singing at karaoke parties, cheering at clubs, having conversations in bars, and exercising in gymnasiums," the scientists wrote.

Notably, too, were the ages of the people who instigated spread outside of the health care settings. "Half ... were 20-39 years of age," the report finds. Which is a reminder: younger people can catch the virus, survive, but at the same time spread it to others who may die from it.

What about touching something with infected droplets? Is that still a risk?

According to the CDC, the coronavirus does not often spread from people touching surfaces. That is, if someone with Covid-19 touches a hand railing, does that make that hand railing dangerous for other people to touch? The CDC is now saying that such events are not a huge risk for Covid-19 transmission.

But, there's a catch: It is still the case that surface transmission is possible. Scientists believe the virus can remain viable on a hard, non-porous surface like plastic or steel for around three days, and a rough surface like cardboard for about a day. You could, conceivably, touch a contaminated surface, and then touch your face, and get sick. (The good news is that even though some virus can remain on a surface for a day or more, the amount of virus on a given surface drops by half after several hours, and then continues dropping.)

Bromage cautions it's just really hard to study surface transmission. In contact tracing studies, it's much easier to ask people who they've been in contact with than to have them remember every surface they've touched.

"I agree with this [CDC] statement," Cevik says, agreeing that surfaces aren't the most significant mode of transmission. "But this does not mean it does not happen." Cevik points me to a contact tracing study that suggests (with a good deal of uncertainty) that some people caught the infection in a mall via the restroom. "Bottom line," she says, "it's still important to maintain personal hygiene and wash hands."

Also consider how scientists recently found live Covid-19 virus in feces. So good bathroom hygiene is still as important as ever.

There are no magic numbers to eliminate risk

It would be great if there were very specific numbers and guidelines we could follow to minimize coronavirus risk to zero.

But there aren't. While 6 feet away from another person, it's not like the virus will immediately decide to drop dead. That's why we need to think of risk in terms of many dimensions: so we can each think critically and not fall back on rules that are too simplified.

"When I first said restaurants were risks, people interpreted that as 'every restaurant is a risk,'" Bromage says. "Each restaurant has its own unique environment, its own unique challenges that need to be worked out. If you've got a large open-seating area, and you can open up the windows and doors ... the risk there is much lower than a boutique restaurant with five tables that creates that really intimate atmosphere."

When we venture out into the world, we need to remember we can reduce risk, but never eliminate it.

"Wearing a mask is not going to completely reduce your risk, hand-washing is not going to completely reduce your risk, and staying a distance away from people in an enclosed space is not going to completely reduce your risk," Haas, the Drexel professor, says. "But the concurrent use of all those strategies will hopefully reduce your risk down to a lower level. We can never get to zero. There's no such thing as zero risk."

And we still need more data, and follow-up on potential exposures. A hair salon in Missouri made headlines when a couple of their hair stylists were reportedly back at work after testing positive for Covid-19. Both hairdressers wore masks, and so did their clients, and a follow-up investigation by their county health department revealed no new infections among the 140 clients they saw.

This data point is a bit anecdotal. "I think they got lucky," Bromage says. "But it does highlight the importance of masks." Perhaps more data will reveal that getting a haircut while everyone is wearing a mask is a low-risk activity.

Contact tracing studies have taught us a lot so far. But as of now, most of this work has been done in Asian countries, which may have different expectations around mask-wearing, among other differences.

"Contact tracing, testing, isolating - these are the building blocks to understand where the transmission is occurring," Cevik says. And the more we learn, the more power we have to stop the spread of this pandemic.
Support Vox's explanatory journalism
Every day at Vox, we aim to answer your most important questions and provide you, and our audience around the world, with information that has the power to save lives. Our mission has never been more vital than it is in this moment: to empower you through understanding. Vox's work is reaching more people than ever, but our distinctive brand of explanatory journalism takes resources - particularly during a pandemic and an economic downturn. Your financial contribution will not constitute a donation, but it will enable our staff to continue to offer free articles, videos, and podcasts at the quality and volume that this moment requires. Please consider making a contribution to Vox today.
*This piece was updated to clarify the temple event occured outdoors.

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6 feet away isn't enough. Covid-19 risk involves other dimensions, too.

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When states had strict stay-at-home orders and lockdowns in place, many decisions about the risk of getting the coronavirus were simple. People didn't have to think about whether dining in a restaurant is safe if the restaurant was closed.

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How to weigh the risk of going out in the coronavirus pandemic, in one chart

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How to weigh the risk of going out in the coronavirus pandemic, in one chart

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There’s a lot of uncertainty and anxiety about going out during a pandemic. Here’s how to think about the risk.

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Since coronavirus lockdowns began in the US, most Americans have drastically changed their patterns: following instructions to stay home, limiting almost all contact with others, and venturing out only for essential trips and exercise.

As states have eased social distancing restrictions, and with the July Fourth weekend approaching, people are beginning to have more options. Between those wanting to patronize newly reopened businesses or socialize in person, and more employers calling people back to work, survey and cellphone data suggests people are already starting to trickle out of their homes.

But for many people, it's really not clear which kinds of gatherings are safe and which aren't. And that uncertainty can spark anxiety.

Fortunately, health experts know more about the coronavirus than they did when the lockdowns began, and they can point us to different levels of risk as we begin to reengage. There's also advice on how to minimize harm.

"There's been a polarization between two purported options of staying home indefinitely ... versus going back to business as usual," Julia Marcus, an infectious disease epidemiologist at Harvard, told me. "The idea of harm reduction gives us a way of thinking about risk as a continuum and thinking about the middle ground between those two options."

Marcus and Boston University epidemiologist Eleanor Murray created an infographic showing the different scales of risk. We at Vox were inspired by it and, with Marcus and Murray's permission, adapted it:

"A lot of people, when they hear that you can't completely get rid of your risk, they think, 'Well, that means that it's inevitable, and I'll just go and do everything that I was normally doing before, and if I get sick, I get sick,'" Murray told me. "But there are lots of things you can do in between nothing and everything."

First and foremost, the advice that has been repeated for much of the past few months remains true: Your home is still the safest place to be during this pandemic. You should continue trying to stay home as much as possible, because the virus is still circulating at a very high rate in many communities. (If you want to be extra careful, some resources, like Covid Act Now, help show how much transmission there is in your area.)

But whether you need to for work or you're simply tired of looking at your home's walls, there are ways to mitigate risk when you go out.

For one, outdoors is generally safer, thanks to the open air - where the virus can more easily disperse - and, potentially, the warm, sunny weather. As Duke health policy expert Mark McClellan told me, "It's a good year for outdoor dining and outdoor shopping and outdoor all kinds of activities."

It also matters who you're hanging out with. It's okay to closely interact with people you live with (unless one of you gets sick; then whoever's sick should isolate). But you should try to keep your distance from people you don't live with. And you should try to avoid interacting with too many people at once; even if it's theoretically possible to keep 6 feet from others in a crowded space, it's still better to avoid it. That's true for the outdoors, but it's especially true for the indoors.

When you go out, also take the now-familiar precautions: Wash your hands. Don't touch your face. Wear a mask, particularly in indoor public spaces. Avoid shared surfaces and crowded settings, and keep physical distance - at least 6 feet - from people you don't live with. If you're 65 or older or have chronic health conditions that could exacerbate Covid-19, you should take all of this advice more seriously.

Separately, experts say it's a good idea to space out trips outside your home as much as possible - ideally, by two weeks, to match the virus's incubation period. You could also establish a "closed circle" with people you want to regularly interact with, in which both sides agree to minimize contact with anyone else (although some experts are skeptical of this idea).

With these tips, you can't completely eliminate the risk of leaving your home. But you can greatly reduce that risk. For some, that could make the prospects of going out - with the benefits that going out can entail for your physical and mental health - much more feasible.

It all begins, though, with the understanding that risk during the coronavirus pandemic is really a spectrum, not a black-and-white choice.

"People will take risks, whether we like it or not," Marcus said. "The best thing we can do is give them strategies to reduce harm in those situations. If we don't do that, we're missing an opportunity."

For more detailed tips for going out and the explanations for them, read Vox's full explainer.
Support Vox's explanatory journalism
Every day at Vox, we aim to answer your most important questions and provide you, and our audience around the world, with information that has the power to save lives. Our mission has never been more vital than it is in this moment: to empower you through understanding. Vox's work is reaching more people than ever, but our distinctive brand of explanatory journalism takes resources - particularly during a pandemic and an economic downturn. Your financial contribution will not constitute a donation, but it will enable our staff to continue to offer free articles, videos, and podcasts at the quality and volume that this moment requires. Please consider making a contribution to Vox today.

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How to weigh the risk of going out in the coronavirus pandemic, in one chart

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Since coronavirus lockdowns began in the US, most Americans have drastically changed their patterns: following instructions to stay home, limiting almost all contact with others, and venturing out only for essential trips and exercise. As states have eased social distancing restrictions, and with the July Fourth weekend approaching, people are beginning to have more options.

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From Camping To Dining Out: Here's How Experts Rate The Risks Of 14 Summer Activities

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From Camping To Dining Out: Here's How Experts Rate The Risks Of 14 Summer Activities

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It has been months of quarantine for many of us. The urge to get out and enjoy the summer is real. But given that coronavirus cases continue to surge in many places, what's safe? We asked a panel of infectious disease and public health experts to rate the risk of summer activities, from backyard gatherings to a day at the pool to sharing a vacation house with another household.

One big warning: Your personal risk depends on your age and health, the prevalence of the virus in your area and the precautions you take during any of these activities. Also, many areas continue to restrict the activities described here, so check your local laws.

And there's no such thing as a zero-risk outing right now. As states begin allowing businesses and public areas to reopen, decisions about what's safe will be up to individuals. It can help to think through the risks the way the experts do.

"We can think of transmission risk with a simple phrase: time, space, people, place," explains Dr. William Miller, an epidemiologist at Ohio State University.

Here's his rule of thumb: The more time you spend and the closer in space you are to any infected people, the higher your risk. Interacting with more people raises your risk, and indoor places are riskier than outdoors.

Dr. Emily Landon, a hospital epidemiologist and infectious diseases specialist at University of Chicago Medicine, has her own shorthand: "Always choose outdoors over indoor, always choose masking over not masking and always choose more space for fewer people over a smaller space."

Our experts shared their thoughts via phone and email interviews.

Jump to an activity: backyard gathering; restaurant; worship service; beach or pool; outdoor party; public restroom; a friend using your bathroom; vacationing with another family; hotel; haircut; shopping mall; nightclub; camping; outdoor sports

1. A BYOB backyard gathering with one other household: low to medium risk

Meeting in a spacious outdoor area with only a small group isn't too risky. But our experts say that safety here depends on whom you invite and what their behaviors have been. "If you have a gathering with one other household that [has] followed social distancing, this would be a low-risk activity," says Dr. Judith Guzman-Cottrill, a pediatric infectious disease expert at Oregon Health & Science University.

What alters risk? To lower risk, avoid sharing food, drinks or utensils - make it a BYO-everything party. Dr. Andrew Janowski, a pediatric infectious diseases expert at Washington University in St. Louis, notes that the food itself isn't the risk but touching shared dishes or utensils could be.

Watch out for drinking, says Dr. Abraar Karan, a physician and public health researcher at Harvard Medical School, as it can make people sloppy about social distancing. It also increases the odds that people will want to use your bathroom. "Once you move into the house with others, the risk profile goes up," he says.

Some experts suggest wearing a face covering, but Landon points out that you can't realistically stay masked while eating and drinking. She suggests an alternative to a meal would be a backyard lawn tournament: That way, "the kids can play together but still with their masks on." It could be fun for the grown-ups too.

2. Eating indoors at a restaurant: medium to high risk

Indoor dining "is still amongst the riskier things you can do," Landon warns. The trouble is, says Miller, "people tend to linger in restaurants. So even if spacing is OK, the duration of exposure is longer." Also, he says, talking "appears to lead to some release of the virus."

Karan notes that one outbreak in Guangzhou, China, took place in a restaurant with no windows and poor ventilation, and the air conditioning appears to have blown droplets between tables.

What alters risk? Janowski says the risk level depends on how well the restaurant has adapted for the pandemic. Eateries should reduce and space out seating, require servers to wear masks and offer easy access to hand-washing stations.

They should also provide single-use options for condiments so you don't have to touch shared ones, says Janowski. And they should close all self-serve areas like soda fountains or buffet tables.

If you do go to a restaurant, look for outdoor seating. Landon says she would go with only members of her household, because "I don't want to have to take my mask off in the close proximity of a bunch of other people."

3. Attending a religious service indoors: high risk

Worship services involve people from different households coming together indoors for an extended time. "All of the ingredients are there for the potential for a lot of people becoming infected in the short amount of time," says Kimberly Powers, an epidemiologist at the University of North Carolina at Chapel Hill. She points to outbreaks linked to churches: In one, 35 out of 92 people who attended a service at a rural Arkansas church developed COVID-19.

Singing - whether from the pews or the choir - is high risk, several experts noted, citing a study of a choir practice in Washington state where over half of attendees became infected.

What alters risk: If people are appropriately socially distanced, wear masks and avoid singing, it may reduce the risk, Karan says. Also, avoid any shared worship items like hymnals, Janowski adds.

Risk goes down if places of worship adapt, Guzman-Cottrill said in May. "My parish began having in-person services last week," she says. The church had advance sign-ups to limit attendance to 25 people. Attendees were required to be healthy, wear face coverings and sit at least 6 feet apart.

4. Spending the day at a popular beach or pool: low to medium risk

As long as you can stay socially distanced, this could be a pretty safe activity, our experts say. The problem is that many beaches have been getting crowded quickly, leading many counties and states to close their beaches periodically, as coronavirus cases sharply rise. So pay attention to conditions and restrictions in your area.

The water itself is not a risk. "The sheer volume of water will dilute out the virus, making the water a highly unlikely source of infection," says Janowski.

What alters risk? The key question is, how close are you to others? "Can you ensure that you can stay 6 feet [or more] from anyone outside of your designated family?" asks Rebecca Katz, director of the Center for Global Health Science and Security at Georgetown University Medical Center.

Watch out for crowds at entry points and bathrooms. Maintain social distance both on land and in the water.

Landon says her biggest worry about pools and beaches is kids. At pools, "they make friends with everyone," she says. "If you want to be able to see grandma for Sunday lunch, because that's what's really important to your family, then you don't want your kids running around with other people's kids."

She says a beach is better than a pool in terms of space. Follow the public health guidelines in your area. If they say it's OK to go to the beach, go early in the morning or late afternoon, when crowds are lower, and look for beaches that mark off spots for people to set up their areas.

5. An outdoor celebration such as a wedding with more than 10 guests: medium to high risk

Family-oriented celebrations are usually a summer tradition, but they come with a lot of risk right now. Many weddings have been postponed, with good reason.

"Outdoors reduces the risk, but as people are celebrating and drinking, it seems like they may not social distance as readily," says Karan, the Harvard physician. "These types of events end up being large crowds where people are having extended face-to-face conversations."

The larger the guest list, the greater the potential that one of them is infected, says Powers, the UNC epidemiologist.

What alters risk? The danger varies greatly depending on the size of the gathering and how closely people gather.

If you are considering hosting a celebration, make it a small one with mostly local guests. "Bringing in people from other communities" is high risk, says Landon, of the University of Chicago. "If people have to travel by car, by plane, from other places, you're really asking for it."

And really think twice about inviting your relatives, particularly older family members or those with underlying conditions. People may feel pressure to attend, even though it's hazardous to their health - and even more so if you emphasize that you're going to try to make it safe, says Landon. One of the largest clusters of deaths from the virus in Chicago occurred after a funeral in which one of the attendees spread it to many of his family members.

6. Using a public restroom: low to medium risk

Restrooms have been designed to prevent disease transmission, says Landon: "There are all sorts of things that you can catch from other people's poop, and you almost never do, because they're set up with all hard surfaces that can be cleaned."

The risk depends on the number of local COVID-19 cases and how clean the bathroom is, says Janowski of Washington University, noting that a bathroom involves multiple high-touch surfaces.

There isn't yet sufficient data to know if there's risk from toilet flushes aerosolizing the virus. Landon says that other viruses, such as norovirus, can be aerosolized by flushing, but norovirus doesn't often spread that way as long as bathrooms are cleaned. The CDC says it's "unclear whether the virus found in feces may be capable of causing COVID-19."

What alters risk: Miller says the main risk comes from restrooms that are small, busy and poorly ventilated - like "those restrooms in a gas station off the highway where the restroom is outside."

Choose a bathroom that looks clean and is well stocked with supplies such as paper towels, soap and toilet paper. Avoid bunching up in a line to use the toilet or staying there long, if you're within 6 feet of others. Wash your hands after you go, and use hand sanitizer on them if you need to touch any surfaces after that.

7. Letting a friend use your bathroom: low risk

Landon doesn't think it's a big risk: "What happens in the bathroom is going to be sucked out of the bathroom ventilation, and you can clean all the hard surfaces really easily."

Miller agrees: "You can run the fan, leave the door open after (so air flows) and clean the bathroom later. And if you use the bathroom after they do, just wash your hands."

What alters risk? It's possible that your friend is infected but asymptomatic, says Janowski. "It would be reasonable to decontaminate the bathroom after a friend uses it, including cleaning the high-touch surfaces of the door, toilet and sink."

8. Going to a vacation house with another family: low risk

Experts said that if both families have been quarantining and limiting their exposure to others, this is pretty safe. "If one family is very active or parents have higher-exposure jobs, then the risk increases," Miller says.

Landon thinks this arrangement could be a good idea, especially if the house is "in the woods where you're not going to have a lot of contact with other people," she says.

What alters risk? Landon suggests talking with the other family beforehand to make sure you share the same expectations for the precautions everyone will take in the two weeks before arrival and while you're there. Ensure that no one has signs of illness - if they do, they need to stay home. Miller recommends cleaning the major surfaces in the house on arrival. "And the more that people can reduce exposure in the days leading up to the trip, the better," he adds. Also, check out the current infection level in the area you're heading to - if it's high, it may be best to postpone.

9. Staying at a hotel: low to medium risk

The consensus is that staying at a hotel is relatively low risk, especially once you're in your room. It's best to limit your time in common areas such as the lobby, gym, restaurant and elevator, where the risk of exposure is higher.

What alters risk? Bring disinfecting wipes to wipe down the TV remote control and other common surfaces. You might also want to remove the bedspread since it may not be cleaned after every guest, suggests Miller. Ask about the hotel's cleaning policies, as many have new COVID-19 protocols. "Beware of the elevators! Use the knuckle of your little or ring finger to press the buttons," says Miller.

Other suggestions: Order room service rather than eating at the restaurant, avoid the exercise room and wear a face covering in public spaces.

10. Getting a haircut: medium to high risk

A haircut involves "close contact and breathing that is extended for several minutes," Karan notes. "This is the primary mode of transmission that we know happens. And cloth masks certainly are not perfect for this."

Janowski says this is one of the highest-risk scenarios on this list, because there's no way to keep 6 feet from someone cutting your hair. "All it takes is [having] one asymptomatic but infected worker, and suddenly many customers are at high risk of infection," he says.

What alters risk? Landon believes the risk is not terribly high if both you and your haircutter wear masks and if COVID-19 is not very prevalent in your area. Look for a salon or barbershop that has (and enforces) policies to protect its employees, like wearing protective gear and sanitizing hands, she says: "By protecting their employees, they're protecting you too."

And make sure that your barber or stylist is all business, says Karan: "Stopping to chat at close distance like this is something we all love doing with our barbers normally. This is not the time for it."

11. Going shopping at a mall: risk varies

How risky this is depends on what kind of mall it is, how crowded it is and how much time you spend there, our panel agreed. "Crowds with high density lead to substantial increase in risk," says Miller. "The major mitigating factor is that people don't mingle in a single place for long."

What alters risk? Outdoor malls are preferable to indoor ones. And empty malls are better than crowded ones. Avoid the food court and go with purpose, not leisure, says Landon: "As much as you may like retail therapy, you should browse online before you go. Know what you're going to pick up or try on. Wear your mask. Go in, look at it. Make your decision and get out."

Be alert while you're there to avoid close contact. "Maintain your space," says Miller. "Try to go at off-peak hours." Bring hand sanitizer, says Guzman-Cottrill, and use it frequently, especially if you touch any shared surfaces like handrails or elevator buttons.

12. Going to a nightclub: high risk

There is consensus among the experts that going to a nightclub is a very high-risk activity. Crowds, ultra-close contact, singing, sweating and inhibition-loosening alcohol are a potent cocktail of risk factors. When drinking, people become less compliant with rules, Miller says, and they may breathe heavier from the dancing - "which means more virus is being shed," he says. If there's an infected person in the mix, the virus can spread easily.

"This is a very high-risk situation for an outbreak, as we saw in South Korea just recently," says Karan, referring to an outbreak tied to several nightclubs and bars. "Don't go to bars or clubs right now."

What alters risk? Nothing makes this a good idea right now. If you want to dance, have a dance party at home with the people in your intimate circle. If it's a small outdoor gathering, dancing under the stars - 6 feet apart - would be much less risky too.

13. Going camping: low risk

"As far as summer activities go, this is least risky from a virus perspective," says Katz, of Georgetown. You're outdoors and isolated. Miller agrees - but he says that if you're going with a group, be sure you can trust your fellow campers. Have they been social distancing and following the guidelines? If not, they could be asymptomatic spreaders of the virus.

What alters risk? Of course, risks can creep in, depending on the particulars. "Are you camping in an isolated outdoor location with your family?" Katz asks - this is the lower-risk scenario. It's more dangerous if you're at a crowded campground with a shared restroom and communal picnic areas, she says. "Sleeping in tents together with others [not from your household] can certainly be a setup for transmission," adds Karan.

Bottom line: The activity itself is low risk, but the people whom you'll be in close contact with during the trip could increase the hazard.

14. Exercising outdoors: low risk

Unless you're playing group sports, exercising outdoors is a good way to burn off steam while staying socially distant. Our experts agree that sports such as golf and tennis are safer than contact sports such as basketball and football. "I would personally avoid contact sports until we have a better sense of transmission risk here," Karan says.

And running? "If you're not on a crowded path where people are brushing past each other, then I think that's a great form of exercise right now," says Powers.

What alters risk? The more people involved in the activity, the higher the risk. It's possible to spread the virus when you're in close proximity to others - even if you're asymptomatic - so it's best to wear a mask if you can't stay socially distanced.

The risk depends on the sport. A game like basketball is tricky, Landon says. "You're touching the ball and you're going to be breathing in each other's faces," so she suggests playing only with people in your household. Tennis carries a much lower risk: "You're far apart on either side. That's definite social distancing," she says.

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From Camping To Dining Out: Here's How Experts Rate The Risks Of 14 Summer Activities

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It has been months of quarantine for many of us. The urge to get out and enjoy the summer is real. But given that coronavirus cases continue to surge in many places, what's safe?

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We will need a comprehensive strategy to reduce the sort of interactions that can lead to more infections.

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We will need a comprehensive strategy to reduce the sort of interactions that can lead to more infections.

Updated at 12:08 a.m. ET on May 26, 2020.
COVID-19 has mounted a sustained attack on public life, especially indoor life. Many of the largest super-spreader events took place inside-at a church in South Korea, an auditorium in France, a conference in Massachusetts. The danger of the indoors is more than anecdotal. A Hong Kong paper awaiting peer review found that of 7,324 documented cases in China, only one outbreak occurred outside-during a conversation among several men in a small village. The risk of infection indoors is almost 19 times higher than in open-air environments, according to another study from researchers in Japan.

Appropriately, just about every public indoor space in America has been shut down or, in the case of essential businesses such as grocers, adapted for social-distancing restrictions. These closures have been economically ruinous, transforming large swaths of urban and suburban life into a morbid line of darkened windows.

Today, states are emerging from the lockdown phase of the crisis and entering a queasy period of reopening. But offices, schools, stores, theaters, restaurants, bars, gyms, fitness centers, and museums will have no semblance of normalcy until we learn how to be safe-and feel safe-inside.
Read: A guide to staying safe as states reopen
To open these spaces, we must be guided by science and expertise. Fortunately for us, researchers are discovering the secrets of how COVID-19 spreads with a combination of clever modeling and detective work.

Before we review the relevant studies and draw out lessons for the future of the great indoors, a brief word of humility. Our understanding of this disease is dynamic. Today's conventional wisdom could be tomorrow's busted myth. Think of these studies not as gospels, but as clues in a gradually unraveling mystery.

1. COVID-PROOF THE OFFICE

On March 8, South Korean public-health officials learned of a COVID-19-positive patient working in a call center in downtown Seoul. The office was located in one of the densest parts of the city, on the 11th floor of a 19-story mixed-use building with hundreds of offices and apartments. More than 1,000 people worked or lived in the building, sharing several elevators and a lobby. The possibility of mass infection was high.

But investigators found that the outbreak was surprisingly concentrated. Of the 97 people in the building who tested positive for the disease, 94 worked on one floor-in the call center. Of those 94, all but a handful worked in one densely packed phone bank. On one side of the floor, the disease was transmitted to two-thirds of employees. But less than 5 percent of the rest of the floor tested positive, as did less than 1 percent of the remainder of the building.

In its conclusion, the Korean CDC writes that the spread of the virus was almost entirely limited to the one floor "despite considerable interaction between workers on different floors in the elevators and lobby." This would suggest that the main facilitator wasn't common touch points, such as doors and elevator buttons, but rather common airspace. When people talk-or sneeze or cough-they produce respiratory droplets that can come to rest in other people's mouths, noses, and lungs. Talking for hours in close quarters, in an unventilated space, can create an ideal petri dish for COVID-19 transmission.

It would be irresponsible to use the Korean study an an illustrative example if it were an outlier. But its main finding is fully in line with the emerging scientific consensus. On Thursday, the Centers for Disease Control and Prevention updated its summary of COVID-19 transmission to clarify that the virus " does not spread easily " from touching surfaces or objects-like, say, elevator buttons. Instead, they wrote, "the virus is thought to spread mainly from person-to-person ... through respiratory droplets."
[ Derek Thompson: What's behind South Korea's COVID-19 exceptionalism? ]
What does the science of indoor transmission mean for the future of the white-collar workplace? In a document shared with the World Bank, the South Korean government set out a 50-point plan for making offices safer. Masks are recommended for all employees. Desks and chairs are to be spread out or arranged in a "chess" or zigzag pattern so that no two individuals are sitting directly across from each other. Cubicles stage a triumphant return, as partitions between co-workers become necessary to block the vocal spray from coughs, sneezes, and loud phone conversations. As for small gatherings, live workshops, and corporate dinners? You can forget about these mixtures of work and social life. "Return home soon after work," the Korean government advises. Long walks outside may replace the water cooler.

Office meetings, once merely obnoxious, are deemed simply noxious. The South Korean government devotes a full page and 12 bullet points to the subject of meetings, but those recommendations can be boiled down to three words that will make meeting-haters rejoice: fewer, smaller, shorter. For meetings that are necessary, large, and long, South Korea recommends masks for all participants and, if possible, open windows. Ventilation, in general, will become a watchword. Many offices may have to overhaul their vent technology or hire professionals to improve airflow throughout the entire office.
Juliette Kayyem: Never go back to the office
Most of these changes would amount to an earthquake for corporate culture, making the office less social, interactive, and serendipitous, and more like the amalgamation of many private workstations. Until we have a vaccine, and perhaps even after, many workers may determine that if they're going to feel as alone in the office as they do at home, there's no point to commuting in the first place.

The future is uncertain, and alternative scenarios are possible, especially if offices adopt widespread tests and temperature checks for months or years before the broad administration of a vaccine. These tests, while strict, might make some people feel safer inside the office than in any other public venue that lacks similar health transparency. With the confidence that work is the safest place other than their own home, some employees might treat the office as a multipurpose isolation unit. Drinking at work, under the protective shield of temperature checks, would make for a safer coronavirus-era ritual than gathering colleagues at an actual bar.

2. COVID-PROOF THE RESTAURANTS

On January 24, a Chinese family of five sat down to lunch in a crowded restaurant in Guangzhou, the most populous city in southern China. They had arrived in the city the previous day from Wuhan. It was a balmy afternoon in Guangzhou, with mid-day temperatures rising into the high 70s, and the restaurant on the third floor of a five-story building was buzzing with more than 80 patrons and no windows. The family gathered around a table along the back wall, between two local families, as an air conditioner pumped cool air across the three tables.
Derek Thompson: The pandemic will change American retail forever
When they left the restaurant, a member of the family felt a fever coming on and, after checking into the hospital, received a diagnosis of COVID-19. Within two weeks, multiple people from each of the three tables-and 10 lunch patrons from the Guangzhou restaurant in total-had been diagnosed with the disease.

When the Guangzhou Center for Disease Control and Prevention investigated the matter, it published a diagram that told a simple story: One asymptomatic person in a restaurant had infected nine others in the direct path of the air conditioner. None of the dozens of other patrons or servers got sick.

It seemed to the researchers that the vector of transmission in the restaurant wasn't a plate of food, an elevator button, or any matter of human touching, but air. Strong airflow from the AC unit had ferried coronavirus-poisoned droplets from table to table. "We conclude that in this outbreak, droplet transmission was prompted by air-conditioned ventilation," the researchers wrote.

Many of the necessary interventions for restaurants will adhere to the same philosophy that guides the reimagining of the office. Masks may become commonplace on servers, as might barriers between tables. In an interview with The Atlantic, the chef and restaurateur Tom Colicchio suggested reducing interactions between patrons and waiters by asking diners to order their meals online before they arrive or on tablets at the table, like in an airport. Social distancing in the kitchen might mean fewer chefs, which could make complex dishes and extravagant plating impossible.

"Until there's a vaccine, I don't think dine-in restaurants will get back to normal in this country," Steve Salis, a restaurant owner in Washington, D.C., told me. "We could introduce things like finger bowls or hand wipes, like you have at some Japanese restaurants, but for every cuisine. We could add public sinks in the dining room, where people can get up and wash their hands at a counter. We might have to retrofit our restaurants to make them easier to clean. As for tables and bar stools, those will have to be socially distanced. At my diner, I might chop up booths to make them more private."
Read: Stanley Tucci on cooking your way through the pandemic
Another idea: Put everything outside. Some American cities, including Berkeley, California, and Cincinnati, have done just that, byannouncing plans to close streets and free up outdoor dining space for restaurants.* But for many cities, wide-scale al fresco dining is unrealistic, not only because of necessary road use, but also because we can't ask the weather to stop. There will be snow in Boston, wind in Chicago, and rain in Seattle. An open-air restaurant is a lovely thing, but ceilings were invented for a reason.

Restaurants will respond to the pandemic as they already have-by cobbling together a variety of businesses, including delivery and curbside pickup, and selling specialty groceries. Even so, their outlook is dire. Colicchio told me that more than half of American restaurants may not reopen. "In my case, for at least two of my restaurants, most of the business comes through private parties and conferences," he said. "For the foreseeable future, that's gone."

3. COVID-PROOF PUBLIC ENTERTAINMENT

On the evening of Tuesday, March 10, 61 singers gathered for choir practice just north of Seattle. It was a standard rehearsal, as members sang in close quarters, shared snacks, and stacked chairs together at the end of the two-and-a-half-hour session.

Five days later, the choir director sent an urgent email to the group. Several members had developed fevers, she said. The following Tuesday's rehearsal was canceled. But by then, it was too late. Fifty-three of the 61 singers became ill, making for an "attack rate" of 87 percent. Three members of the choir were hospitalized. Two died.

The Washington choir represents the most aggressive outbreak I have come across, with an attack rate almost twice as high as the Korean call center. It had many features we've already established to be dangerous: an intimate crowd gathered in a small room, sharing air, food, and surfaces. But what if singing accelerated the transmission of the disease?
Read: How the pandemic will end
In a study subsequently published in the Centers for Disease Control and Prevention's "Morbidity and Mortality Weekly Report," researchers emphasized that "the act of singing, itself," might have contributed to transmission, because choir members were belting out more of the virus. Some people-known as "superemitters"-release more particles into the air when they speak, because they are unusually loud or slobbery talkers. But even normal gabbers can release an exceptional number of droplets if they're singing or theatrically projecting their voice.

Many super-spreader events have been ceremonies that involve group prayers and exclamations, such as religious gatherings. On February 16, a 61-year-old Korean woman with COVID-19 triggered hundreds of infections when she prayed with 1,000 worshippers in a large windowless church in Daegu, South Korea. (To this day, more than 60 percent of Korea's COVID-19 cases are in Daegu.) Two days later, in France, several hundred Christian worshippers from around the world packed into a dark auditorium in the small town of Mulhouse for an annual festival. French authorities have since linked more than 2,000 global cases to this one meeting, including cases in French Guyana, Corsica, Burkina Faso, and Switzerland.

These stories, combined with the science of large-droplet and airborne transmission, suggest that social distancing isn't enough: We need saliva control too. Other countries are doing so, already. Germany has reportedly banned singing at religious services, and South Korea has prohibited spitting in its professional baseball league.

Spittle rules won't be enough to make our public entertainment places safer, either. We will need a comprehensive strategy to reduce the sort of interactions that can lead to more infections. "When we go back to sports stadiums and theaters, people are going to have to adjust their expectations," says Joseph Allen, an assistant professor of exposure-assessment science at Harvard's T. H. Chan School of Public Health.

First, he told me, full-capacity stadiums will be impossible in the social-distancing age, and most attendees will be advised to wear masks. Second, everything that can be made touchless should be, including ticketing and concessions. "To avoid clustering at the hot-dog stands, stadium food vendors should serve as much as possible directly to people's seats," Allen said. Third, public-entertainment venues will have to reimagine queuing. "Our theories about crowd control, which are dominated by concerns for physical security, typically squeeze large numbers of people into a scarce number of heavily guarded entrances," he said. But in a pandemic, tightly packed queues are the very hazard we want to avoid. "It'll be very important to reduce crowding at the entrance of stadiums and theaters by adding additional entrance points or staggering admissions by time to avoid overcrowding, Allen said.

When you put all of these stories, studies, blueprints, and advice together, it amounts to a relatively straightforward pandemic playbook. For memory's sake, let's reduce the major takeaways to a convenient acronym: SAFE.

- Social distancing: This one you probably knew before you read this article. Keep a healthy distance between yourself and others-six feet is a good general rule-especially when you are near them for an extended period of time.

- Airflow awareness: Every noncontact activity-talking, eating, working out-becomes significantly safer when you take it outside. As the previously mentioned Japanese study and Hong Kong survey indicated, the odds of transmission in a closed, indoor space are several orders of magnitude higher than in open-air environments.

- Face masks: Wear them. They're not just for you; they're for everybody around you.

- Expectoration (sorry for using a fancy word for spit to make the acronym work): COVID-19 appears to spread both through large-droplet transmission, such as from sneezes, and through the airborne transmission of smaller, aerosolized droplets, such as those that spray out of the mouths of talkers. Beware especially of indoor environments and activities that naturally include lots of gabbing (such as a long office meeting), singing (such as a choir practice), shouting (such as a high-school gym), or heavy breathing (such as an intense indoor workout class).

Read: America's patchwork pandemic is fraying even further
As an indoor person myself-and a lover of theater, sports, and restaurants-it's painful to think about the range of activities that will be pinched in the next year and the businesses and lives that will suffer for it.

Toward the end of my reporting for this piece, I emailed a national-security worker who also teaches singing in the Washington, D.C., area. She's heard that in-person singing may be off-limits until a vaccine is widely available, a possibility that would shutter musicals and vocal lessons for a year or longer. "Despite all the chaos and intense news, this has been the thing that has hit the hardest," she said. So, she's planning to offer singing lessons on Zoom.

America's public spaces will have to show a similar flexibility and resiliency to make it through the next year. Even as the United States reopens, some old rituals-such as going to bars, group workouts, and packed concerts-will have to remain paused. People will still drink and sweat and sing, just differently. Eventually, the old world will come back. The great indoors will return. But until then, Americans will have to balance their rituals and nostalgia with a humble respect for our unfolding understanding of COVID-19.
* This article previously misstated that Berkeley, California, had closed its streets to make space for outdoor dining. The city has announced plans to do so, but has not yet implemented them.

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We will need a comprehensive strategy to reduce the sort of interactions that can lead to more infections. Updated at 12:08 a.m. ET on May 26, 2020. COVID-19 has mounted a sustained attack on public life, especially indoor life. Many of the largest super-spreader events took place inside-at a church in South Korea, an auditorium in France, a conference in Massachusetts.

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How to fight fear and anxiety when quarantine ends

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How to fight fear and anxiety when quarantine ends

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Vox
Eleanor Cummins
May 20, 2020

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Part of the May Issue of The Highlight, our home for ambitious stories that explain our world.

Governments around the world are rolling back some of the most severe aspects of quarantine. After months of being cooped up and kept apart, friends and family will eventually begin to socialize again. Some workers will return to the office, and public spaces - from restaurants to movie theaters - will begin to implement strategies to make returning customers feel safe.

Few of us will be the same coming out of quarantine as we were going in: People with preexisting mental health conditions lost many of the routines that helped them cope, exacerbating their problems in the process. Many have experienced fresh hardship, like the loss of a job or the death of a loved one, which they likely weren't able to properly mourn. And everyone has been forced to dramatically alter how they live, work, and accomplish even the most mundane tasks, such as shopping for groceries.

Emerging from such circumstances will create unique side effects. Though some states have begun to reopen parts of their economies, with the virus still active, for many people, FOMO may have been replaced by FOGO - a.k.a. the fear of going out. While some people are ready to rub shoulders with strangers, others will be apprehensive about returning to the social sphere, in part because without a vaccine, leaving our homes will come with a real risk of infection. But anxieties about resuming public life have also been magnified by our months indoors, with the lack of exposure to people and places only intensifying our fears about the outside world.

"We're going to have to work through this quarantine state of mind even when the physical quarantine has lifted," Sheva Rajaee, founder of the Center for Anxiety and OCD in Irvine, California, told Vox in April. In some countries, the psychic stress is already showing. In Wuhan, China, where the first cases of Covid-19 were reported, the lockdown has lifted - but restaurants are empty, active temperature checkpoints dot the city, and some residents continue to hide inside, fearing a second wave of outbreaks.

How Americans will adapt to the new normal is the question on everyone's minds. Vox asked five psychologists, whose expertise ranges from disaster resilience to the epidemiology of mental health, what they expect to see in the coming months. Their advice for coping with the unprecedented challenges, edited for length and clarity, follows.

Accept that your anxieties are normal
Roxane Cohen Silver, professor of psychological science, medicine, and health at the University of California, Irvine
I've been conducting research on how individuals and communities respond to traumatic life events for about 40 years. This is unlike anything we've experienced before, for a variety of reasons: There's an invisible threat. We don't know how bad this will get. We don't know how long this will last. And, importantly, this is a global threat.

There are a few strategies that can help. None of them are perfect. People should moderate the amount of media they're engaging with; a steady diet of bad news is not psychologically beneficial. People should understand that their feelings are normal and natural, and they're not going crazy. This is a very unusual and stressful and worrisome time. It's okay to be feeling anxious. And there are many, many, many people experiencing losses - and those are real, and those should not be minimized.

But so much is out of the control of the individual. It depends on the ability to test whether people have the antibodies to the coronavirus. It depends on whether there is any sort of treatment. And in the absence of a vaccine, we'll need people to feel confident in the authorities and the science telling us what is risky and what is less risky.

After 9/11, there were large concerns people would never get on an airplane again. So there were three things that the government did that led people to feel comfortable getting on an airplane: They introduced plainclothes air marshals, the airlines hardened the doors so cockpits can only be opened from the inside, and they introduced screenings at the airport. That's just one example of the ways our public authorities can engage in an information campaign to make people more comfortable.

Learn to manage your emotional response to fear
Christopher Pittenger, director of the OCD Research Clinic at Yale University
I work primarily with people with obsessive compulsive disorder. They often struggle with uncertainty and difficulty managing what's dangerous and what's not. That's something we're all struggling with now. Their reaction to the pandemic has been interesting. Some people with OCD are certainly struggling, but others are doing surprisingly well. Everyone else's fear of uncertainty and their desire to avoid contamination is validating. And in this crisis, the ambiguity is gone. That clarity can be reassuring.

As we go back to going out into the world to socialize, it's going to come with some real amount of risk. And we're all going to have to deal with the question: How much of that risk am I willing to tolerate?

One of the things to do is to talk through a scenario systematically and just accept the fact that there isn't going to be absolute certainty, and learn to manage that emotional response to uncertainty. This is something we'll do in therapy, not just for OCD but for a lot of anxiety disorders. It's called exposure and response prevention. We'll go ahead and trigger the emotional response - we'll look at the spider, we'll allow our hands to be contaminated, whatever it may be - and sit there and tolerate the emotion. What often happens is there's risk, and that leads to anxiety, and that anxiety leads to more anxiety because we tend to assume, "If I'm anxious, something dangerous must be happening." If we can learn to label the emotion and recognize them as signals that may be useful sometimes but don't mean you're in danger, then we can try to break that cycle of the anxiety or the fear feeding on itself and learn to tolerate it better.

Practice mindfulness, and cut out unhealthy routines
Rossi Hassad, epidemiologist and psychology professor at Mercy College
If you ask any mental health expert today, they'll say disaster equals post-traumatic stress disorder. During the Spanish flu, we didn't have that classification. But if you go back to anecdotal reports and a few narratives from the 1918-'19 epidemic, the description fits: Spanish flu survivors reported sleep disturbances, depression, mental distraction, dizziness, and difficulty coping at work.

Post-traumatic stress disorder is directly related to the intensity of one's exposure to the traumatic event. The prevalence is generally reported to be 30 to 40 percent among direct victims, 10 to 20 percent among rescue workers, and 5 to 10 percent for the general population.

After a disaster, there is also an increase in cases of major depressive disorder. There tends to be an increase in substance use problems. And with the Spanish flu, the death rate in the US was positively correlated with the rate of suicide. When there's so much uncertainty, there are feelings of hopelessness.

Most people are resilient, and they will weather this very well. If they do have mild symptoms, they will bounce back emotionally. But some people will need some form of psychological support, from self-care to professional care.

Mindfulness, as simple as it sounds, runs very deep. We encourage people to be mindful of how they consume the news. We want them to engage in healthy routines and be mindful of the use of tobacco, alcohol, and other drugs, which can worsen your mental health and physical well-being in the long term. And if people need more support, we want them to know they can contact their state and city health departments, the CDC, and other organizations to get information on accessing professional services.

Fight apprehension by keeping yourself distracted
George Bonanno, director of the Loss, Trauma, and Emotion Lab at Columbia University Teachers College
This is so unique. And it's not a traumatic moment. It's chronically stressful, so we begin to fall apart physically, and the stress response starts to fail to work properly, and then you start getting depressed or anxious.

The natural reactions we have to adverse events are adaptive, but they can become uncoupled from an actual threat and become a general apprehension about the world.

We've been trying to identify what makes people resilient for 30 years. We've identified a bunch of stuff: optimism, confidence in your coping strategies, mindfulness, social connection. But scientifically, all of these things have small effect sizes. Optimism explains maybe 3 or 5 percent of resilience. Even if you add all these things up, you don't get much of the story. The reason is that they don't always work because life is complicated. There are no magic bullets. There are no three things or five things that you can do that will solve the problem. We have to be creative.

Friends have already told me that they're watching movies and [if they] see someone touch, they freak out a little bit now - "Don't touch that!" I imagine some people will be uneasy for some time afterwards, and will be until there are more assurances. We have to use the tools we have at our disposal in the meantime. We need social contact - people have been Zooming with their friends. Humor is really good. It's not a panacea, but smiling and laughing works. People should distract themselves; there are plenty of movies to watch right now. But the idea is whatever you do, if it helps you, as long as it doesn't become prolonged or harmful, that's great.

Get involved to help stave off feelings of powerlessness
Susan Clayton, environmental psychologist at the College of Wooster
Our behavior has been changed so dramatically. Right now there's this real sense of unreality for a lot of people. In the early days, it was like, okay, we'll shelter in place for two or three weeks and it will all go back to normal. It quickly became clear that was not the case. Now, when we transition back to a different lifestyle, we have to go slowly or it could be stressful, especially if we reopen the economy before we have a vaccine or a treatment.

The virus is going to force us to take baby steps. But it will be good for our mental health, and also our physical health, to try not to come out of the pandemic all at once. I think there are some things we are doing that are better - that we might want to continue to do - even when worries about the pandemic subsides: having more business meetings virtually, sleeping in, families spending more quality time together. The need to go slowly does encourage us to be mindful and make more deliberate choices. It's like, "All right, I'm going to do this one thing differently," and not return to all our old behaviors immediately. We need to think about how this experience can contribute in a positive way to who you are.

With both climate change and the coronavirus, people feel very helpless because it is this global problem, and they feel nothing they can do as individuals will make a difference. But what the response to the coronavirus has shown us is that we can make pretty dramatic changes when we have to. It is helpful to get involved in some way. People can try to make their community more sustainable, or it could be political action, or it could be finding another group of people to meet with and talk about these problems. Taking action can help overcome that feeling of powerlessness, and that's good for your mental health.
Eleanor Cummins reports on the intersection of science and popular culture. She previously wrote about social-distancing scofflaws Support Vox's explanatory journalism and misguided celebrity pandemic social media for The Highlight.

Every day at Vox, we aim to answer your most important questions and provide you, and our audience around the world, with information that has the power to save lives. Our mission has never been more vital than it is in this moment: to empower you through understanding. Vox's work is reaching more people than ever, but our distinctive brand of explanatory journalism takes resources - particularly during a pandemic and an economic downturn. Your financial contribution will not constitute a donation, but it will enable our staff to continue to offer free articles, videos, and podcasts at the quality and volume that this moment requires. Please consider making a contribution to Vox today.

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How to fight fear and anxiety when quarantine ends

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Part of the May Issue of The Highlight, our home for ambitious stories that explain our world. Governments around the world are rolling back some of the most severe aspects of quarantine. After months of being cooped up and kept apart, friends and family will eventually begin to socialize again.

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Staying safe isn't just about hygiene and distance. It's about time, too.

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Staying safe isn't just about hygiene and distance. It's about time, too.

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CNN
Eric Levenson
May 19, 2020

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coronavirus infection isn't just about hygiene and distance. it's about time

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Staying safe isn't just about hygiene and distance. It's about time, too.

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The longer you stay in an environment that may contain the virus, the higher the risk of getting sick.

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Safety Advice for Reopening: How to Reduce Your Risks as Coronavirus Lockdowns Ease

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Safety Advice for Reopening: How to Reduce Your Risks as Coronavirus Lockdowns Ease

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The Wall Street Journal
Andrea Petersen
May 12, 2020

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As communities and businesses across the country begin to reopen, more people are weighing whether-and how-they should head into work and, perhaps, visit restaurants, retail shops and hair salons.

Public-health experts generally agree that to reopen society safely, communities need widespread testing so officials can be confident that the number of coronavirus cases in the population is low and people who are positive can be quarantined. Communities also need a system to trace people who have come into contact with positive cases so they too can be isolated, doctors say. "Otherwise you simply let everybody out for a few days and two weeks later have a surge in cases and have to start all over again," says Gregory Poland, director of the Mayo Clinic's Vaccine Research Group in Rochester, Minn. The U.S. so far largely lacks widespread testing and tracing, he says. "Most communities do not have that capacity."

So the safest move for most people is still to stay home as much as possible. But if you do go out, there are ways to reduce the risks. Here's what the experts say:

Commuting

Walking or biking to work or driving your own car are the safest options, says Dr. Poland. "If you're on a train or bus, you have to realize that this is a very effective petri dish for the spread of respiratory pathogens," he says. If you must use public transportation, wear a face mask and "be really cautious about hand hygiene," using hand sanitizer and washing hands with soap and water for at least 20 seconds, says Daniel Kuritzkes, chief of the division of infectious diseases at Brigham and Women's Hospital in Boston.

Taking a taxi or using Uber or Lyft is generally less risky than the bus or train, "particularly if the driver is wearing a mask," says Dr. Kuritzkes. You're likely near only one potentially infectious person rather than the dozens on public transportation, and the driver's mask "will provide some protection for the passenger" by trapping droplets that are emitted while coughing, sneezing or exhaling. Dr. Kuritzkes notes that those old-school plexiglass shields in some taxis can provide some protection, too. He suggests opening the car windows to increase air circulation, which can dilute the number of virus particles per volume of air.

The Centers for Disease Control and Prevention has issued recommendations for ride-share and taxi drivers that include wearing face-coverings in public and asking customers to handle their own bags. Uber says it has shipped disinfecting wipes and spray and 800,000 face masks to drivers around the country, prioritizing hard-hit areas like New York City. Lyft says it has distributed more than 40,000 "sanitizing products" and has begun handing out "hundreds of thousands of cloth face coverings" to drivers.

In the Office

Some businesses are planning to bring back only a portion of workers to the office or are instituting shifts to allow for social distancing. Those moves are important, doctors say.

Elevators can be a problem, says George Rutherford, professor of epidemiology at the University of California, San Francisco, since it is nearly impossible to keep an appropriate distance from other people in such a small space. Everyone should be wearing masks. And "face the wall so you're not breathing in someone else's breath," he says.

Surfaces like elevator buttons, doorknobs and printer buttons should be disinfected regularly. Even so, employees should use a tissue or paper towel to handle them and immediately use sanitizer or wash their hands, says Dr. Poland. "Every hard surface should be considered potentially contaminated," he says.

But it is the office bathroom that is the real hot zone, says Dr. Poland. Some research has found that the novel coronavirus is present in stool and can remain in the digestive tract long after it has been cleared from the respiratory system. Many company bathrooms have removed the lids from toilets so "when they flush, it causes a plume cloud and any virus that was in that stool is now on every surface you can culture, the air ducts, the ceilings, the floors and you," he says. Dr. Poland suggests waiting until no one else is in the bathroom to use it. Avoid the hand dryers, too, since the forced air "very effectively disseminates virus everywhere," he says.

Use a paper towel on doorknobs and to turn faucets on and off, too. And, it goes without saying: Wash your hands for at least 20 seconds.

At a Restaurant

The National Restaurant Association has released "Covid-19 Reopening Guidance" that includes recommendations such as spacing tables at least 6 feet apart, providing hand sanitizer for customers and eliminating unwrapped straws from self-service drink stations.

Benjamin Chapman, a professor of food safety at North Carolina State University, who co-authored the restaurant recommendations, says the biggest risk in restaurants is being around other people. He suggests avoiding any crowds that can occur while waiting for tables or clustered at the bar. Donald K. Milton, professor of environmental and occupational health at the University of Maryland School of Public Health, says outdoor dining is safest since there will be more ventilation and air flow.

Dr. Chapman notes that restaurants should either be using paper menus that are thrown away after every patron or disinfecting reusable menus between customers. Even better would be to avoid physical menus altogether by downloading the menu on your phone, he says. Customers should be wary of "all high touch surfaces" like salt and pepper shakers, pens and those little leather holders that waitstaff use to present your check. (Hand sanitizing and hand washing are key here.) Dr. Chapman says that restaurant cutlery and dishes are less of a concern-though not risk-free-since they are heated, cleaned and sanitized and handled only by employees who should be trained in food safety. "I'm much more worried about the 40 or 50 other patrons that might have touched a menu."

A study published in the New England Journal of Medicine in March found that the virus that causes Covid-19 can live on cardboard for up to 24 hours and on hard surfaces such as stainless steel and plastic for two to three days. There appears to be no risk of contracting the virus by eating it in cooked food, experts say.

In a Retail Store

Supermarkets, liquor stores and hardware stores, among others, have been operating throughout the pandemic and have employed social-distancing measures like limiting the number of shoppers, keeping people apart in checkout lines and encouraging shoppers to order online and have items delivered or picked up. Other retailers could quickly adopt these practices. But public-health experts urge people to limit nonessential shopping trips. "It is harder to have a dozen people browsing in the shop trying to see what they want or going in changing rooms to try on clothing," Dr. Kuritzkes says.

At the Hairdresser or Barbershop

Check out those YouTube tutorials, because Dr. Poland urges people to postpone trips to the salon until there's more evidence that community transmission of the novel coronavirus is very low. Dr. Kuritzkes concurs. "It's going to be basically rolling the dice and hoping the person doing your hair hasn't been recently exposed by another client or somebody in their neighborhood and is shedding virus." He notes that some research has found that people are most contagious in the two or so days before they exhibit symptoms of Covid-19.

If you do go to the hairdresser or barber shop, Dr. Milton says because "people are going to be really close for an extended period of time," it is important that both client and professional wear masks. Dr. Kuritzkes says that it probably is safer to have your hairdresser make a house call (if he or she is willing) and cut your hair outside in your backyard.

Outdoor Exercise

As long as you can maintain social distance, public health experts generally agree that solo outdoor exercise is safe. Dr. Poland says he does caution people against going running with someone they don't live with since "the nature of more rapid and deep exhalation puts people around you at greater risk."

Golf courses are now open in many states. And Dr. Kuritzkes says as long as golfers can maintain an appropriate social distance on the course, "I can't see that as a serious threat." The bigger concern is "people gathering in the clubhouse having drinks together afterward." Tennis is relatively low-risk, too, he says, since people are usually far apart and outdoors-as long as you maintain distance. But avoid touching your face and use hand sanitizer and wash your hands after handling the ball, he says. Basketball and soccer are more concerning since "people do literally get in each others' faces," Dr. Kuritzkes says.

With more beaches open, swimming in the ocean or in a lake or surfing should be fine if you keep your distance from other people, says Dr. Rutherford. That is the same for pools as chlorine kills the virus, he says.

At the Gym

Health experts suggest waiting to head back to the gym. "You've got everybody huffing and puffing, coughing, touching everything," says Dr. Poland. Dr. Kuritzkes says he can envision a way to do a yoga or spin class relatively safely if participants were spaced out and wearing masks and if the equipment was thoroughly disinfected between users. But he says that it would be difficult to "decontaminate things often enough or reliably enough to make it safe to go back to doing free weights or weight machines until we can be confident enough that any one person in the gym isn't carrying infection."

In a Movie Theater

Movie theaters are now allowed to open in Georgia and Texas. But even if theaters implement strict social-distancing protocols like blocking out rows and spacing family groups 6 feet apart, the problem is that people spend such a long time (sometimes two hours or more) sitting in them, says Dr. Kuritzkes. That gives people that many more opportunities to breathe in any virus that may be lingering in the air.

Coming Home

Health-care workers often have elaborate personal-safety rituals for when they return home, like stripping down in the garage, throwing clothes in the wash and immediately taking showers before they join their families. Front-line employees like bus drivers and grocery store staffers often do the same. The University of Maryland's Dr. Milton says most other workers probably don't have to go through such a rigorous regimen. "We should wash our hands as soon as we get home," he says. "Really the bigger risk is what you could be carrying inside of you."

Write to Andrea Petersen at andrea.petersen@wsj.com

Copyright ©2020 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8

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Safety Advice for Reopening: How to Reduce Your Risks as Coronavirus Lockdowns Ease

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As communities and businesses across the country begin to reopen, more people are weighing whether-and how-they should head into work and, perhaps, visit restaurants, retail shops and hair salons. Public-health experts generally agree that to reopen society safely, communities need widespread testing so officials can be confident that the number of coronavirus cases in the population is low and people who are positive can be quarantined.

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Why It’s Important To Push Back On ‘Plandemic’—And How To Do It

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Why It’s Important To Push Back On ‘Plandemic’—And How To Do It

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Forbes
Tara Haelle
May 8, 2020

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Why It's Important To Push Back On 'Plandemic'-And How To Do It

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By now you've probably heard about or even seen the video "Plandemic" that's been spreading like wildfire through social media networks. This article is not the one you should give to your friend or relative or coworker who shared the video.

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Professor Erin Bromage
May 6, 2020

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Please read this link to learn about the author and background to these posts. It seems many people are breathing some relief, and I'm not sure why. An epidemic curve has a relatively predictable upslope and once the peak is reached, the back slope can also be predicted.

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Read this before you venture out in public

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Read this before you venture out in public

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CNN
Scottie Andrew
May 1, 2020

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read this before you go out in public amid the coronavirus pandemic - cnn

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Read this before you venture out in public

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If your state is reopening, it's imperative you visit public spaces safely. Read on for how to safely navigate resturants, beaches, gyms and more.

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Why the Coronavirus Is So Confusing: A guide to making sense of a problem that is now too big for any one person to fully comprehend

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Why the Coronavirus Is So Confusing: A guide to making sense of a problem that is now too big for any one person to fully comprehend

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The Atlantic
Ed Yong
April 29, 2020

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A guide to making sense of a problem that is now too big for any one person to fully comprehend

Joan Wong

On March 27, as the U.S. topped 100,000 confirmed cases of COVID-19, Donald Trump stood at the lectern of the White House press-briefing room and was asked what he'd say about the pandemic to a child. Amid a meandering answer, Trump remarked, "You can call it a germ, you can call it a flu, you can call it a virus. You know, you can call it many different names. I'm not sure anybody even knows what it is."
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That was neither the most consequential statement from the White House, nor the most egregious. But it was perhaps the most ironic. In a pandemic characterized by extreme uncertainty, one of the few things experts know for sure is the identity of the pathogen responsible: a virus called SARS-CoV-2 that is closely related to the original SARS virus. Both are members of the coronavirus family, which is entirely distinct from the family that includes influenza viruses. Scientists know the shape of proteins on the new coronavirus's surface down to the position of individual atoms. Give me two hours, and I can do a dramatic reading of its entire genome.

But much else about the pandemic is still maddeningly unclear. Why do some people get really sick, but others do not? Are the models too optimistic or too pessimistic? Exactly how transmissible and deadly is the virus? How many people have actually been infected? How long must social restrictions go on for? Why are so many questions still unanswered?

The confusion partly arises from the pandemic's scale and pace. Worldwide, at least 3.1 million people have been infected in less than four months. Economies have nose-dived. Societies have paused. In most people's living memory, no crisis has caused so much upheaval so broadly and so quickly. "We've never faced a pandemic like this before, so we don't know what is likely to happen or what would have happened," says Zoë McLaren, a health-policy professor at the University of Maryland at Baltimore County. "That makes it even more difficult in terms of the uncertainty."

But beyond its vast scope and sui generis nature, there are other reasons the pandemic continues to be so befuddling-a slew of forces scientific and societal, epidemiological and epistemological. What follows is an analysis of those forces, and a guide to making sense of a problem that is now too big for any one person to fully comprehend.

I. The Virus

Because coronavirus wasn't part of the popular lexicon until SARS-CoV-2 ran amok this year, earlier instances of the term are readily misconstrued. When people learned about a meeting in which global leaders role-played through a fictional coronavirus pandemic, some wrongly argued that the actual pandemic had been planned. When people noticed mentions of "human coronavirus" on old cleaning products, some wrongly assumed that manufacturers had somehow received advance warning.

Read: Why the coronavirus has been so successful
There isn't just one coronavirus. Besides SARS-CoV-2, six others are known to infect humans-four are mild and common, causing a third of colds, while two are rare but severe, causing MERS and the original SARS. But scientists have also identified about 500 other coronaviruses among China's many bat species. "There will be many more-I think it's safe to say tens of thousands," says Peter Daszak of the EcoHealth Alliance, who has led that work. Laboratory experiments show that some of these new viruses could potentially infect humans. SARS-CoV-2 likely came from a bat, too.

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It seems unlikely that a random bat virus should somehow jump into a susceptible human. But when you consider millions of people, in regular contact with millions of bats, which carry tens of thousands of new viruses, vanishingly improbable events become probable ones. In 2015, Daszak's team found that 3 percent of people from four Chinese villages that are close to bat caves had antibodies that indicated a previous encounter with SARS-like coronaviruses. "Bats fly out every night over their houses. Some of them shelter from rain in caves, or collect guano for fertilizer," Daszak says. "If you extrapolate up to the rural population, across the region where the bats that carry these viruses live, you're talking 1 [million] to 7 million people a year exposed." Most of these infections likely go nowhere. It takes just one to trigger an epidemic.

Once that happens, uncertainties abound as scientists race to characterize the new pathogen. That task is always hard, but especially so when the pathogen is a coronavirus. "They're very hard to work with; they don't grow very well in cell cultures; and it's been hard to get funding," says Vineet Menachery of the University of Texas Medical Branch. He is one of just a few dozen virologists in the world who specialize in coronaviruses, which have attracted comparatively little attention compared with more prominent threats like flu. The field swelled slightly after the SARS epidemic of 2003, but then shrunk as interest and funding dwindled. "It wasn't 'til MERS came along [in 2012] that I even thought I could have an academic career on coronaviruses," Menachery says.

The tight group of coronavirologists is now racing to make up for years of absent research-a tall order in the middle of a pandemic. "We're working as hard as possible," says Lisa Gralinski, a virologist at the University of North Carolina. "Our space is so intermingled that we can't socially distance among ourselves much."

One small mercy, she notes, is that SARS-CoV-2 isn't changing dramatically. Scientists are tracking its evolution in real time, and despite some hype about the existence of different strains, the virologists I've spoken with largely feel that the virus is changing at a steady and predictable pace. There are no signs of "an alarming mutation we need to be worried about," Gralinski says. For now, the world is facing just one threat. But that threat can manifest in many ways.

II. The Disease

SARS-CoV-2 is the virus. COVID-19 is the disease that it causes. The two aren't the same. The disease arises from a combination of the virus and the person it infects, and the society that person belongs to. Some people who become infected never show any symptoms; others become so ill that they need ventilators. Early Chinese data suggested that severe and fatal illness occurs mostly in the elderly, but in the U.S. (and especially in the South), many middle-aged adults have been hospitalized, perhaps because they are more likely to have other chronic illnesses. The virus might vary little around the world, but the disease varies a lot.

Read: The coronavirus's unique threat to the South
This explains why some of the most important stats about the coronavirus have been hard to pin down. Estimates of its case-fatality rate (CFR)-the proportion of diagnosed people who die-have ranged from 0.1 to 15 percent. It's frustrating to not have a firm number, but also unrealistic to expect one. "Folks are talking about CFR as this unchangeable quantity, and that is not how it works," says Maia Majumder, an epidemiologist at Harvard Medical School and Boston Children's Hospital.

The CFR's denominator-total cases-depends on how thoroughly a country tests its population. Its numerator-total deaths-depends on the spread of ages within that population, the prevalence of preexisting illnesses, how far people live from hospitals, and how well staffed or well equipped those hospitals are. These factors vary among countries, states, and cities, and the CFR will, too. (Majumder and her colleagues are now building tools for predicting regional CFRs, so local leaders can determine which regions are most vulnerable.)

The variability of COVID-19 is also perplexing doctors. The disease seems to wreak havoc not only on lungs and airways, but also on hearts, blood vessels, kidneys, guts, and nervous systems. It's not clear if the virus is directly attacking these organs, if the damage stems from a bodywide overreaction of the immune system, if other organs are suffering from the side effects of treatments, or if they are failing due to prolonged stays on ventilators.

Read: Why some people get sicker than others
Past coronavirus epidemics offer limited clues because they were so contained: Worldwide, only 10,600 or so people were ever diagnosed with SARS or MERS combined, which is less than the number of COVID-19 cases from Staten Island. "For new diseases, we don't see 100 to 200 patients a week; it usually takes a whole career," says Megan Coffee, an infectious-disease doctor at NYU Langone Health. And "if you see enough cases of other diseases, you'll see unusual things." During the flu pandemic of 2009, for example, doctors also documented heart, kidney, and neurological problems. "Is COVID-19 fundamentally different to other diseases, or is it just that you have a lot of cases at once?" asks Vinay Prasad, a hematologist and an oncologist at Oregon Health and Science University.

Prasad's concern is that COVID-19 has developed a clinical mystique-a perception that it is so unusual, it demands radically new approaches. "Human beings are notorious for our desire to see patterns," he says. "Put that in a situation of fear, uncertainty, and hype, and it's not surprising that there's almost a folk medicine emerging." Already, there are intense debates about giving patients blood thinners because so many seem to experience blood clots, or whether ventilators might do more harm than good. These issues may be important, and when facing new diseases, doctors must be responsive and creative. But they must also be rigorous. "Clinicians are under tremendous stress, which affects our ability to process information," McLaren says. "'Is this actually working, or does it seem to be working because I want it to work and I feel powerless?'"

Read: Why does the president keep pushing a malaria drug?

III. The Research

Since the pandemic began, scientists have published more than 7,500 papers on COVID-19. But despite this deluge, "we haven't seen a lot of huge plot twists," says Carl Bergstrom, an epidemiologist and a sociologist of science at the University of Washington. The most important, he says, was the realization that people can spread the virus before showing symptoms. But even that insight was slow to dawn. A flawed German study hinted at it in early February, but scientific opinion shifted only after many lines of evidence emerged, including case reports, models showing that most infections are undocumented, and studies indicating that viral levels peak as symptoms appear.

This is how science actually works. It's less the parade of decisive blockbuster discoveries that the press often portrays, and more a slow, erratic stumble toward ever less uncertainty. "Our understanding oscillates at first, but converges on an answer," says Natalie Dean, a statistician at the University of Florida. "That's the normal scientific process, but it looks jarring to people who aren't used to it."

For example, Stanford University researchers recently made headlines after testing 3,330 volunteers from Santa Clara County for antibodies against the new coronavirus. The team concluded that 2.5 to 4.2 percent of people have already been infected-a proportion much higher than the official count suggests. This, the authors claimed, means that the virus is less deadly than suspected, and that severe lockdowns may be overreactions-views they had previously espoused in opinion pieces. But other scientists, including statisticians, virologists, and disease ecologists, have criticized the study's methods and the team's conclusions.

The scientific discussion of the Santa Clara study might seem ferocious to an outsider, but it is fairly typical for academia. Yet such debates might once have played out over months. Now they are occurring over days-and in full public view. Epidemiologists who are used to interacting with only their peers are racking up followers on Twitter. They have suddenly been thrust into political disputes. "People from partisan media outlets find this stuff and use a single study as a cudgel to beat the other side," Bergstrom says. "The climate-change people are used to it, but we epidemiologists are not."

In an earlier era, issues with the Santa Clara study would have been addressed during peer review-the process in which scientific work is assessed by other researchers before being published in a journal. But like many COVID-19 studies, this one was uploaded as a preprint-a paper that hasn't yet run the peer-review gauntlet. Preprints allow scientists to share data quickly, and speed is vital in a pandemic: Several important studies were uploaded and discussed a full month before being published.

Preprints also allow questionable work to directly enter public discourse, but that problem is not unique to them. The first flawed paper on hydroxychloroquine and COVID-19 was published in a peer-reviewed journal, whose editor in chief is one of the study's co-authors. Another journal published a paper claiming that the new coronavirus probably originated in pangolins, after most virologists had considered and dismissed that idea.
Read: Don't believe the COVID-19 models
Such scrutiny will become ever more necessary as the pandemic wears on. Julie Pfeiffer of UT Southwestern, who is an editor at the Journal of Virology, says that she and her colleagues have been flooded with submitted papers, most of which are so obviously poor that they haven't even been sent out for review. "They shouldn't be published anywhere," she says, "and then they end up [on a preprint site]." Some come from nonscientists who have cobbled together a poor mathematical model; others come from actual virologists who have suddenly pivoted to studying coronaviruses and "are submitting work they never normally would in a rush to be first," Pfeiffer says. "Some people are genuinely trying to help, but there's also a huge amount of opportunism."

IV. The Experts

Last month, the legal scholar Richard Epstein claimed that "the current organized panic in the United States does not seem justified" and that as the pandemic continued, "good news is more likely than bad." His piece was widely circulated in conservative circles and the Trump administration. When asked about his lack of epidemiological training in an interview with The New Yorker 's Isaac Chotiner, Epstein responded, "One of the things you get as a lawyer is a skill of cross-examination. I spent an enormous amount of time over my career teaching medical people about some of this stuff." His essay initially speculated that 500 Americans would die from COVID-19. He later updated that estimate to 5,000. So far, the death toll stands at 58,000, and is still rising.

Many other non-epidemiologists seem to have similarly accrued expertise in the field. The military historian Victor Davis Hanson proffered the widely shared idea that the coronavirus has been spreading in California since last fall-a claim disproved by genetic studies showing that the earliest U.S. case likely arrived in January. During a White House meeting, the economist Peter Navarro reportedly pointed to a pile of hydroxychloroquine studies and said, "That's science, not anecdote" to Anthony Fauci, who has worked in public health for five decades and directs the National Institute of Allergy and Infectious Diseases. The Silicon Valley technologist Aaron Ginn self-published an article on Medium called "Evidence Over Hysteria-COVID-19" that was viewed millions of times before being debunked by Bergstrom and taken down.

Read: We are living in a failed state
Expertise is not just about knowledge, but also about the capacity to spot errors. Ginn couldn't see them in his own work; Bergstrom could. The rest of us are more likely to fall in the former group than the latter. We hunger for information, but lack the know-how to evaluate it or the sources that provide it. "This is the epistemological crisis of the moment: There's a lot of expertise around, but fewer tools than ever to distinguish it from everything else," says Zeynep Tufekci, a sociologist at the University of North Carolina and an Atlantic contributing writer. "Pure credentialism doesn't always work. People have self-published a lot of terrible pieces on Medium, but some of the best early ones that explained stuff to laypeople were from tech guys."

Bergstrom agrees that experts shouldn't be dismissive gatekeepers. "There's a lot of talent out there, and we need all hands on deck," he says. For example, David Yu, a hockey analyst, created a tool that shows how predictions from the most influential COVID-19 model in the U.S. have changed over time. "Looking at that thing for, like, an hour helped me see things I hadn't seen for three weeks," Bergstrom says.

A lack of expertise becomes problematic when it's combined with extreme overconfidence, and with society's tendency to reward projected confidence over humility. "When scientists offer caveats instead of absolutes," Gralinski says, "that uncertainty we're trained to acknowledge makes it sound like no one knows what's going on, and creates opportunities for people who present as skeptics." Science itself isn't free from that dynamic, either. Through flawed mechanisms like the Nobel Prize, the scientific world elevates individuals for work that is usually done by teams, and perpetuates the myth of the lone genius. Through attention, the media reward voices that are outspoken but not necessarily correct. Those voices are disproportionately male.

The idea that there are no experts is overly glib. The issue is that modern expertise tends to be deep, but narrow. Even within epidemiology, someone who studies infectious diseases knows more about epidemics than, say, someone who studies nutrition. But pandemics demand both depth and breadth of expertise. To work out if widespread testing is crucial for controlling the pandemic, listen to public-health experts; to work out if widespread testing is possible, listen to supply-chain experts. To determine if antibody tests can tell people if they're immune to the coronavirus, listen to immunologists; to determine if such testing is actually a good idea, listen to ethicists, anthropologists, and historians of science. No one knows it all, and those who claim to should not be trusted.

In a pandemic, the strongest attractor of trust shouldn't be confidence, but the recognition of one's limits, the tendency to point at expertise beyond one's own, and the willingness to work as part of a whole. "One signature a lot of these armchair epidemiologists have is a grand solution to everything," Bergstrom says. "Usually we only see that coming from enormous research teams from the best schools, or someone's basement."

V. The Messaging

In the early months of the pandemic, while the coronavirus blazed through China, even veteran disease experts seemed to misjudge the odds that the epidemic would become a full-blown pandemic. On January 26, Fauci himself said the virus posed a "very, very low risk to the United States" and was a concern for public-health officials, but not the public. Many journalists offered similar reassurances, and frequently compared the coronavirus threat with the allegedly greater danger of flu.

Some officials may have been motivated to avoid disproportionate panic, of the kind that gripped the U.S. during the Ebola outbreak of 2014. The instinct to be calm and measured is laudable-until it isn't. "Alarmism is equated with misinformation, and a lot of it is misinformation. But when you do have something coming, no one feels empowered to say: 'This one isn't alarmism,'" Tufekci, the sociologist, says. "There's a cultural script that we play, and when the script changes, it takes time to shift to a new one."

The narrative that experts underplayed the risks isn't fully correct, though. On January 26, Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health tweeted, "We should be planning for the possibility that [the coronavirus] cannot be contained." He followed with a list of recommendations, several of which-more diagnostics, more protective equipment, transparent communication-the U.S. is still struggling to meet. Four days later, Scott Gottlieb, the former FDA commissioner, and Luciana Borio, who was part of the National Security Council's now-dissolved pandemic-preparedness office, similarly urged the government to " act now " to prevent an American epidemic. "I hope the lesson people take from this is not 'Experts were wrong,'" Tufekci says. "If you followed the right people, they were overwhelmingly right. We just didn't put them in the right place so we could hear them."

Read: The WHO shouldn't be a plaything for great powers
The same could be said of the White House and other U.S. officials who repeatedly assured Americans in January, February, and even March that their risk was low. That might have initially been true, Inglesby says, but officials should have noted that the true extent of the disease was unknown; that there wasn't a way of measuring it, because tests weren't in place; that the virus had already spread globally; and that control measures such as airport screening and travel bans have historically been unsuccessful. "The fuller statements take longer to explain, but that's how it is in outbreaks." Inglesby says. "There's a lot of uncertainty, and we shouldn't try to tidy it up."

The impulse to be reassuring is understandable, but "the most important thing is to be as accurate as possible," Inglesby says. "We should give people information so they can do what they think is right. We should tell people what we don't know and when we'll know more." (The WHO is learning: On April 25, after wrongly tweeting that "there is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from infection," they offered a longer and more accurate explanation.)

If officials-and journalists-are clear about uncertainties from the start, the public can better hang new information onto an existing framework, and understand when shifting evidence leads to new policy. Otherwise, updates feel confusing. When the CDC suddenly reverses its position on wearing masks, without having previously clarified why the issue was so divisive, it seems like an arbitrary flip-flop. "That's a dangerous way to communicate," says Kate Starbird at the University of Washington, who studies how information flows during a crisis. "It contributes to diminishing trust in organizations. And when people don't have a place they can go for trusted information, it makes them vulnerable to disinformation."

VI. The Information

During news events like Trump's impeachment trial, people mostly share information to signal their beliefs, says Renée DiResta of Stanford, who studies how narratives spread online. But in a disaster, people tend to share information "to be useful to their community," she says. Sharing offers agency. It allows people to collectively make sense of a situation riddled by anxiety and uncertainty. "But when an earthquake happens, you talk to your neighbors and in a few days, you've figured out what's going on," Starbird says. "For COVID-19, the uncertainty is persistent."

The pandemic's length traps people in a liminal space. To clarify their uprooted life and indefinite future, they try to gather as much information as possible-and cannot stop. "We go seeking fresher and fresher information, and end up consuming unvetted misinformation that's spreading rapidly," Bergstrom says. Pandemics actually "unfold in slow motion," he says, and "there's no event that changes the whole landscape on a dime." But it feels that way, because of how relentlessly we quest for updates. Historically, people would have struggled to find enough information. Now people struggle because they're finding too much.
Read: Trump's dangerously effective coronavirus propaganda
It does not help that online information channels are heavily personalized and politicized, governed by algorithms that reward certain and extreme claims over correct but nuanced ones. On Twitter, false information spreads further than true information, and at six times the speed. But "this is not just a problem of the internet," DiResta says. "For a lot of people, what is true is what the people I've chosen to trust in my community say is true." Those dynamics meant that, at least initially, liberal and conservative Americans had very different understandings of the pandemic.

As the reality of the pandemic becomes clearer, the partisan gap is rapidly closing. But as time passes, misinformation, which refers to misleading stories that are circulated in good faith, will give way to disinformation-falsehoods deliberately seeded "to leverage the disaster for political power," Starbird says. Amid the psychological loam of fear and uncertainty, conspiracy theories are germinating like weeds.

The daily briefings from the White House have only exacerbated the confusion. Trump has repeatedly tried to downplay the pandemic and rewrite his role in mishandling it. His playbook is his usual one: Deny responsibility, find a scapegoat, incite a culture war, and bend reality to his will by baldly stating his version of it (even when that version contradicts itself). The list of Trump's lies about the coronavirus is long and growing, as are their consequences. His promotion of hydroxychloroquine led to shortages of the drug. His false claim that anyone who wants a test can get one sent droves of worried well to already-stretched hospitals.
Read: The Trump presidency is over

Rosen also argues that the media's default rhythm of constant piecemeal updates is ill-suited to covering an event as large as the pandemic. "Journalists still think of their job as producing new content, but if your goal is public understanding of COVID-19, one piece of new content after another doesn't get you there," he says. "It requires a lot of background knowledge to understand the updates, and the news system is terrible at [providing that knowledge]." Instead, the staccato pulse of reports merely amplifies the wobbliness of the scientific process, turns incremental bits of evidence into game changers, and intensifies the already-palpable sense of uncertainty that drives people toward misinformation.

If the media won't change, its consumers might have to. Starbird recommends slowing down and taking a moment to vet new information before sharing it. She herself is spending less time devouring every scrap of pandemic news, and more time with local sources. It's the equivalent, she says, of "hand-washing for the infodemic." And it might dispel the illusion that the pandemic can be tracked in real time.

VII. The Numbers

The rapid pace of new information creates the sense that we can accurately monitor the pandemic as it happens. But daily numbers tell a distorted story. As April wears on, case counts suggest that the pandemic is plateauing in parts of the U.S. But it's hard to know for sure. As my colleagues Robinson Meyer and Alexis Madrigal have reported, 20 percent of Americans who are tested for the coronavirus are still getting positive results. This figure is higher than almost every other developed country and has held steady over time. It suggests that the U.S. is still mostly testing people who are very likely to be infected and is still missing the majority of cases. If so, cases could have leveled off because the U.S. has maxed out its ability to find infected people.

This concern complicates the government's plan to start reopening the country after a "downward trajectory of documented cases within a 14-day period." If the case number is illusory, this criterion is meaningless. "I'd want to know that we're doing enough testing to be confident that those numbers really are stabilizing," says Dean, the University of Florida statistician. "I'm still not convinced we're in a good place."

When looking at case counts, remember this: Those numbers do not show how many people have been infected on any given day. They reflect the number of tests that were done ( which is still insufficient), the lag in reporting results from those tests ( which can be long), and the proportion of tests that are incorrectly negative ( which seems high). Likewise, daily death counts do not offer a real-time glimpse at the virus's toll. Because of delays in reporting, they tend to be lower on weekends.

False positives are a problem, too. Many companies and countries have pinned their hopes on antibody tests, which purportedly show whether someone has been infected by the coronavirus. One such test claims to correctly identify people with those antibodies 93.8 percent of the time. By contrast, it identifies phantom antibodies in 4.4 percent of people who don't have them. That false-positive rate sounds acceptably low. It's not. Let's assume 5 percent of the U.S. has been infected so far. Among 1,000 people, the test would correctly identify antibodies in 47 of the 50 people who had them. But it would also wrongly spot antibodies in 42 of the 950 people without them. The number of true positives and false positives would be almost equal. In this scenario, if you were told you had coronavirus antibodies, your odds of actually having them would be little better than a coin toss.
Read: No testing, no treatment, no herd immunity, no easy way out
None of this means that all bets are off and the pandemic is unquantifiable. The case count might be wrong, but it's almost certainly too low rather than too high, and it's more likely off by a factor of 10 than 100. The numbers still matter; they're just messy and hard to interpret, especially in the moment. On my phone, I can see weather patterns, the position of every plane in the sky, and the number of people currently reading this article, all in real time. But I cannot get the same immediate information about the pandemic. The numbers I see say as much about the tools researchers are using as the quantities they are measuring. "I think people underestimate how difficult it is to measure things," Dean says. "For us who work in public health, measuring things is, like, 80 percent of the problem."

If measuring the present is hard, predicting the future is even harder. The mathematical models that have guided the world's pandemic responses have been often portrayed as crystal balls. That is not their purpose. They instead describe a range of possibilities, and help scientists and policy makers to simulate what might happen pending different courses of action. Models reveal many possible fates, and allow us to choose one. And while distant projections are necessarily blurry, the path ahead is not unknowable. "The long-term is like modeling the trajectory of a falling leaf, but the short-term is like modeling a falling bowling ball," says Dylan Morris, an infectious-disease modeler at Princeton. Uncertainties about the year ahead shouldn't cloud "how devastatingly and terrifyingly certain we can be" about the immediate consequences if the pandemic isn't controlled, he adds.

VIII. The Narrative

In the final second of December 31, 1999, clocks ticked into a new millennium, and ... not much happened. The infamous Y2K bug, a quirk of computer code that was predicted to cause global chaos, did very little. Twenty years later, Y2K is almost synonymous with overreaction-a funny moment when humanity freaked out over nothing. But it wasn't nothing. It actually was a serious problem, which never fully materialized because a lot of people worked very hard to prevent it. "There are two lessons one can learn from an averted disaster," Tufekci says. "One is: That was exaggerated. The other is: That was close."

Last month, a team at Imperial College London released a model that said the coronavirus pandemic could kill 2.2 million Americans if left unchecked. So it was checked. Governors and mayors closed businesses and schools, banned large gatherings, and issued stay-at-home orders. These social-distancing measures were rolled out erratically and unevenly, but they seem to be working. The death toll is still climbing, but seems unlikely to hit the worst-case 2.2 million ceiling. That was close. Or, as some pundits are already claiming, that was exaggerated.

The coronavirus is not unlike the Y2K bug-a real but invisible risk. When a hurricane or an earthquake hits, the danger is evident, the risk self-explanatory, and the aftermath visible. It is obvious when to take shelter, and when it's safe to come out. But viruses lie below the threshold of the senses. Neither peril nor safety is clear. Whenever I go outside for a brief (masked) walk, I reel from cognitive dissonance as I wander a world that has been irrevocably altered but that looks much the same. I can still read accounts of people less lucky-those who have lost, and those who have been lost. But I cannot read about the losses that never occurred, because they were averted. Prevention may be better than cure, but it is also less visceral.

The coronavirus not only co-opts our cells, but exploits our cognitive biases. Humans construct stories to wrangle meaning from uncertainty and purpose from chaos. We crave simple narratives, but the pandemic offers none. The facile dichotomy between saving either lives or the economy belies the broad agreement between epidemiologists and economists that the U.S. shouldn't reopen prematurely. The lionization of health-care workers and grocery-store employees ignores the risks they are being asked to shoulder and the protective equipment they aren't being given. The rise of small anti-lockdown protests overlooks the fact that most Republicans and Democrats agree that social distancing should continue "for as long as is needed to curb the spread of coronavirus."
Read: How the pandemic will end
And the desire to name an antagonist, be it the Chinese Communist Party or Donald Trump, disregards the many aspects of 21st-century life that made the pandemic possible: humanity's relentless expansion into wild spaces; soaring levels of air travel; chronic underfunding of public health; a just-in-time economy that runs on fragile supply chains; health-care systems that yoke medical care to employment; social networks that rapidly spread misinformation; the devaluation of expertise; the marginalization of the elderly; and centuries of structural racism that impoverished the health of minorities and indigenous groups. It may be easier to believe that the coronavirus was deliberately unleashed than to accept the harsher truth that we built a world that was prone to it, but not ready for it.

In the classic hero's journey -the archetypal plot structure of myths and movies-the protagonist reluctantly departs from normal life, enters the unknown, endures successive trials, and eventually returns home, having been transformed. If such a character exists in the coronavirus story, it is not an individual, but the entire modern world. The end of its journey and the nature of its final transformation will arise from our collective imagination and action. And they, like so much else about this moment, are still uncertain.

Ed Yong is a staff writer at The Atlantic, where he covers science.

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A guide to making sense of a problem that is now too big for any one person to fully comprehend On March 27, as the U.S. topped 100,000 confirmed cases of COVID-19, Donald Trump stood at the lectern of the White House press-briefing room and was asked what he'd say about the pandemic to a child.

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Drinking, bathing in, or injecting yourself with bleach can be deadly—and it won’t cure COVID-19

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Drinking, bathing in, or injecting yourself with bleach can be deadly—and it won’t cure COVID-19

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Popular Science
Rachel Feltman
April 24, 2020

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Drinking, bathing in, or injecting yourself with bleach can be deadly-and it won't cure COVID-19

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There is no evidence that using disinfectants on or in your body is a good way to fight off disease or even detox.

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3 Coronavirus Facts Americans Must Know Before Returning To Work, School

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3 Coronavirus Facts Americans Must Know Before Returning To Work, School

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Forbes
Robert Pearl, M.D.
April 21, 2020

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Getty Images

We can't un-bungle our nation's COVID-19 response. Political leaders acted too slowly, health agencies committed unforced errors with testing kits and, amid the confusion, an information fog settled over the land.

Americans remain afraid, perplexed and chronically misinformed (despite wall-to-wall coronavirus coverage across the leading cable-news programs and print publications).

To counter the uncertainty, any plan to get us out of the coronavirus crisis must first acknowledge and broadly communicate three immutable, scientific facts.
Fact 1: Staying home saves lives but it doesn't kill the virus
Weeks of social distancing and self-isolation in the United States have made us all safer. These precautions slowed the spread of COVID-19, thus helping to " flatten the curve." Doing so buys hospitals and critical care centers enough time to staff up and stock diagnostic tests, protective gear and ventilators.

However, it's imperative that Americans understand these measures do not eliminate the virus. By staying home (and six feet apart from each other), we did not (and cannot) outlast our opponent.

Whenever we return to our jobs, schools and community gatherings-be it this spring, summer or fall-infections will rise. It's not a prediction. It's a biological fact.

To avoid overwhelming critical care services, local reopening strategies must keep a multitude of safety precautions in place, especially those meant to protect the most vulnerable populations. The elderly-and those with chronic illnesses like heart and lung disease-remain at highest risk and therefore must continue to shelter in place. As such, local governments should provide them with food, housing and safe transport as needed.
Fact 2: We're in this for the long-haul
There's a bitter paradox brewing in the United States. The spread of COVID-19 has been, and still is, largely predictable based on objective and publicly available data. Yet most people-including Wall Street investors, governors and sports-starved fans -seem unable to comprehend the mathematical realities of a virus that spreads exponentially.

As federal and state officials hammer out plans to reopen the economy, our nation must accept the unfortunate truth that every path forward is booby-trapped.

The coronavirus will persist until there is either (a) a safe vaccine ( still 12 to 18 months away) or (b) until there is "herd immunity," whereby two-thirds of the nation (about 200 million people) must become infected, recover and develop the appropriate antibodies. This, too, will take at least a year.

A theoretical third option, which involves aggressively testing and quarantining all infected individuals, no longer applies. In the United States, that ship sailed back in February when the number of cases soared into the tens of thousands with no way of tracking carriers and their recent contacts. At this point, too many people are infected and too many of the infected show no symptoms, making it impossible to rid the virus through containment.

So, what options do we have? Trump recently announced he is "authorizing each individual governor of each individual state to implement a reopening, and a very powerful reopening, plan of their state."

This is a dangerous tightrope to walk at the state level. Governors must ensure they don't ease restrictions too quickly or too slowly.

Reports of increased mental health crises, domestic violence incidents and suicides demonstrate the urgency of getting people out of their houses and back to their normal lives. At the same time, the Spanish Flu of 1918 reminds us that the "second wave" of a virus can prove just as deadly as the first.

Medical requirements for reopening the country must therefore include:

Limiting exposure, likely for a year. Restaurants and shops should reopen only under three conditions: (1) community hospitals have additional capacity to handle an uptick in demand, (2) all local businesses agree to restrict indoor capacity based on the six-foot rule, and (3) all staff wear masks.

Making tests free and convenient. Testing for COVID-19 requires the insertion a 6-inch long swab into the back of the nasal passage through one nostril and rotating the swab several times for 15 seconds. It's a painful process, which is why Americans won't consent to a reopening strategy that involves daily tests. Nevertheless, local governments need to make testing available at no cost to anyone with COVID-19 symptoms. Those who are confirmed should immediately self-quarantine.

Helping health officials. In parallel to molecular testing for the disease, our nation must ramp up serological testing, which can identify those that were infected, have since recovered and developed antibodies-thus telling health officials how close we are to herd immunity.

Fact 3: Our nation is ignoring the most important metric
Every day, cable-news chyrons display the latest numbers of confirmed COVID-19 cases and deaths. These figures are eye-popping, but they tell us very little about the relative safety of reopening the country.

That's why it's important for all Americans to acquaint themselves with a different, more-informative metric.

R₀ (pronounced "R naught") is a number that indicates the contagiousness of an infectious disease like COVID-19. Specifically, it tells us the average number of unvaccinated (or otherwise vulnerable) people who will contract a disease from one contagious individual.

For example, measles has an R₀ of 12 to 18, which means that one infected person will transmit the virus to as many as 18 unprotected people. The R ₀ for HIV is 4.0 and the seasonal flu is 1.2.

Early data suggests the R ₀ of COVID-19 is between 2.5 and 3.0. However, the actual number depends not only on the biology of the disease but on the actions people take.

For example, when people observe social distancing and adhere to rigid shelter-in-place measures, the number drops. In the UK, where strict lockdown protocols and frequent testing are in place, the R ₀ is low (currently estimated to be 0.62). Conversely, the R ₀ value grows much higher in densely packed conditions including sports arenas, large conferences and events like Mardi Gras.

As explained here, the R ₀ value shows the potential transmissibility of the disease, and its careful monitoring constitutes both the safest and fastest way for the United States to implement a reopening strategy:

If R₀ is less than 1.0, each infected person transmits the virus to less than one other individual. As a result, the disease incidence will decline and the virus will slowly die out.

If R₀ equals 1.0, each infected person will transmit the virus to one other individual. As a result, the infection rate will remain constant (though the curve will be flat) and there won't be a future spike (or second wave).

If R ₀ is more than 1.0, each infected person will pass the virus onto more than one individual. As such, the number of infected people will rise and the number of individuals needing critical care can quickly surge.

If we want Americans to better understand the relative safety and preparedness of local and regional "reopening" plans, we must base our decisions on this important number.
Facts Save Lives
About 90% of the country has been on some form of lockdown order for several weeks now. People are losing patience. As our nation eagerly eyes the future, we must let science inform our decisions about reopening small businesses, allowing students to return to class and easing social restrictions.

If we move ahead too quickly, we risk losing lives unnecessarily. If we move too slowly, we also risk unnecessary deaths. We can't allow politics or panic to push our nation too far in either direction. These three facts, based on science, should guide the way.

... Read More

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3 Coronavirus Facts Americans Must Know Before Returning To Work, School

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We can't un-bungle our nation's COVID-19 response. Political leaders acted too slowly, health agencies committed unforced errors with testing kits and, amid the confusion, an information fog settled over the land. Americans remain afraid, perplexed and chronically misinformed (despite wall-to-wall coronavirus coverage across the leading cable-news programs and print publications).

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Is the Virus on My Clothes? My Shoes? My Hair? My Newspaper?

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Is the Virus on My Clothes? My Shoes? My Hair? My Newspaper?

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NY Times
Tara Parker-Pope
April 17, 2020

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Is the Virus on My Clothes? My Shoes? My Hair? My Newspaper? (Published 2020)

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We asked the experts to answer questions about all the places coronavirus lurks (or doesn’t). You’ll feel better after reading this.

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No, You Don't Need To Disinfect Your Groceries. But Here's How To Shop Safely

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No, You Don't Need To Disinfect Your Groceries. But Here's How To Shop Safely

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NPR
Maria Godoy
April 12, 2020

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The vast majority of the country is under lockdown right now. But stay-at-home orders come with a few exceptions - like grocery shopping.

Many of us are still venturing out to stock up on food and toiletries. But what's the safest way to shop during this pandemic? And what should you do once you've brought your haul home?

We asked infectious disease, virology and food safety experts to share their tips about safe grocery shopping - and what you can stop worrying about.
Know the dangers - focus on the people, not the food
Many people worry about the possibility of picking upthe coronavirusfrom things like grocery store conveyor belts or cereal boxes. But every expert NPR spoke with agrees that the biggest risk when it comes to groceries is being inside the store itself with other people who may be infected.

"While it is possible to contract the virus [from contaminated surfaces], the majority of transmission is probably going to be from respiratory droplets, which you're exposed to when you're around other people," says Angela Rasmussen, a virologist at the Center for Infection and Immunity at Columbia University's Mailman School of Public Health.
Avoid crowds and shop quickly
Donald Schaffner, a food microbiologist and distinguished professor at Rutgers University, advises that you look for a grocery store that limits the number of shoppers who are allowed to go in at one time. While that might lead to a long line outside, it's also likely to make it easier to practice social distancing inside the store - staying at least 6 feet away from other people. And once you are in there, he says, focus on getting in and out as fast as possible to minimize your risk.

"Be as efficient as possible in the store," Schaffner says. "Have a list. Move through the store quickly and efficiently. Get out of the way. Be respectful of other people. Maintain social distance while you're in the store."
Wear a face covering
Given the growing evidence that people can shed the virus before they are showing symptoms, they might not know they're infected either. That's why the Centers for Disease Control and Prevention now recommends that people wear cloth face coverings out in public, and some stores now require shoppers to wear them - not so much to protect you as to protect other people from you in case you are infected.
Go alone
Dr. David Aronoff, director of the Division of Infectious Diseases at Vanderbilt University Medical Center, says to go to the store alone if you can, because bringing the whole family shopping is just going to add to crowding in the aisles - and could potentially raise your household's risk of infection too.

"If you have three people living together and all three people go to the store, even if all three people have a low risk of getting infected at an individual level, as a group they've tripled their risk, essentially," says Aronoff, who recently wrote about safe food practices during this pandemic in the medical journal JAMA.
Sanitize carts and hands
Once you are in the store, make sure to sanitize the handles of your cart or basket. Many stores do this for customers now, but it doesn't hurt to bring your own hand sanitizer or disinfecting wipes if you have them. Be sure to avoid touching your face while you are there, until you can sanitize your hands again.

One other tip, from Rasmussen: Don't use your cellphone while you're in the store, because a "phone is a great way to get your hands right up next to your face."
Skip the gloves
"Gloves are not magic," Schaffner says. "Gloves don't make you invulnerable. As soon as you touch something with your gloved hand, that contamination is on the gloves."

Rasmussen agrees. "I've seen a lot of people wearing gloves out in public, and they just kind of wear them all day and do a lot of normal activities, like talk on their phone, potentially eat, potentially handle food that they're going to eat later with those gloves on," she says. "And that's not great practice."

She leaves the gloves at home and sanitizes or washes her hands instead - before entering the store, after leaving and again once she gets home.

Rachel Graham, a virologist who studies coronaviruses at the University of North Carolina's Gillings School of Global Public Health, also skips the gloves. But if you do choose to wear them, she says be sure to remove them properly: "The best way to remove gloves that might be contaminated is to basically grab them from the inside on your palm side and pull them out like you're pulling off a sock, so you end up turning them inside out."
Give the cashier some space
While grocery shopping may stress you out, it's the workers at the grocery store who are more at risk, because they interact with many customers daily. Protect them by making sure you stand 6 feet away, or as far as you can, while checking out.

As for whether to use self-checkout or a cashier, look for the option that allows you the most room to maintain social distance. It all depends on how the store is set up. Some checkout counters now have plexiglass between the cashier and the paying customer. In that situation, says Aronoff, going to a cashier is fine, especially if one or both of you is wearing a mask or face covering.
Choose no-touch payment when you can
If you've got a no-touch option like Apple Pay or Google Pay, use it. If that's not an option, a credit card machine with a chip reader can be no-touch, notes Graham. She's personally avoiding cash at the moment, because earlier research has found that cash currency can harbor lots of microorganisms.

However, Rasmussen notes that we don't know how long this coronavirus survives on cash. And she says that if your credit card transaction requires you to touch a keypad, that's a "high-touch surface" that could potentially harbor other pathogens, if not the coronavirus. That said, "I don't want to encourage people to be extreme germophobes," Rasmussen says.

Cash or credit, she says, just make sure to sanitize your hands (and your credit card) after the transaction.
Don't drive yourself crazy disinfecting your groceries
Many shoppers are now following elaborate routines to disinfect their groceries, thanks to a viral video put out by a Michigan family doctor. But all of the experts we spoke with say that disinfecting and hand-washing every last item in your grocery haul is really not necessary. You might find it comforting to know that none of these experts are doing this themselves.

Rasmussen explains that the probability of getting infected from a contaminated surface is not zero, but it is fairly low. That's because respiratory droplets would have to have landed on the exact spot on, say, a box of cereal that you are touching. And even then, you'd have to get enough residual virus on your hand to start an infection - and you'd have to transfer that virus to your face. Bottom line: If you follow good hand-hygiene practices - washing your hands after unpacking your groceries, before cooking and before eating - then, she says, your risk is probably "very, very low."

As Aronoff notes, "Time is really on your side here." That's because as soon as the virus lands on a surface, it starts to lose infectiousness. "After 24 hours, the vast majority of virus is no longer infectious," he says. And after 72 hours, he notes that research has found the virus is trace or undetectable on most surfaces.So if you know that you're not going to use a can of soup for two or three days, he says, just put it away, wash your hands and go about your day. And one more thing: Make sure to wipe down your countertops after you unpack, using a household disinfectant registered with the Environmental Protection Agency.

If you're still worried and it's a food that doesn't need to be refrigerated, Graham says just leave it out for 24 hours.
If you really want to wash your groceries, don't use disinfecting spray or wipes Rinse fresh produce in plain water - and eat your veggies!
If it somehow lessens your anxiety to wipe down every last jar of jelly, there's no harm in that, experts agree. But Graham warns that if you feel compelled to wipe, it might be wise to stick to soap and water. "A lot of the packaging that groceries come in is really not meant to be sprayed with disinfectant, and you [could] actually end up contaminating your food," she says.

Schaffner adds that disinfecting sprays and wipes are meant to be used on hard surfaces, which would not include many of the kinds of plastics or cardboard used for food packaging.
Should you shower or change clothes after shopping? It depends
Some people are advocating washing produce in soap and water. But Schaffner says that's a bad idea because it's possible that if you ingest soap residue, it could lead to diarrhea or vomiting. He says the best thing is just to rinse your produce in cold water. If it's an item with a tough skin, you can use a vegetable brush.

And Schaffner says, please don't reduce your consumption of fresh fruit or vegetables. "There's just no evidence that these foods can transmit the virus or can cause COVID-19," he says. Plus, he says, produce offers valuable nutrients that are especially important in these stressful times.

"I personally don't like to do a full de-con [de-contamination] when I get home from the store," Rasmussen says. "I wash my hands. I'm not routinely putting my face and mouth all over my clothing."
Still anxious? Order online
But, she adds, "people with small children might consider otherwise, since kids - especially little kids - are maybe not so concerned about where they put their mouths or their hands." She says it comes back to personal comfort. "If you feel more comfortable changing clothes and taking a shower after you come back from an essential errand, then by all means do so," she says.
A word about frozen food
Graham adds that if you live with someone who is at high risk for severe disease with COVID-19, showering and changing might be a reasonable precaution to take.

One simple way to stop worrying about grocery shopping and to practice social distancing is online delivery.You can pay ahead of time online and have the groceries delivered outside your door with no face-to-face contact. Just remember, while you're staying home safe, workers are putting themselves at risk to collect and deliver your food. So be sure to tip generously. As for what to do with unpacking those groceries, experts say the advice is the same as if you'd gone to the store yourself.

Some of you have asked if freezing food kills the virus. The answer is no. Refrigerating or freezing would actually help the virus survive longer - that's why research labs freeze virus samples to preserve them, as Graham notes. But if you're worried about handling a frozen dinner, just throw away the packaging and remember to wash your hands after you've removed the food, Rasmussen says.

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No, You Don't Need To Disinfect Your Groceries. But Here's How To Shop Safely

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The vast majority of the country is under lockdown right now. But stay-at-home orders come with a few exceptions - like grocery shopping. Many of us are still venturing out to stock up on food and toiletries. But what's the safest way to shop during this pandemic?

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The Atlantic
Ed Yong
April 15, 2020

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The fight against the coronavirus won't be over when the U.S. reopens. Here's how the nation must prepare itself.

Joan Wong

Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

Updated at 11:50 a.m. ET on April 15, 2020.
What a difference a few months can make.

What will May bring? Or June? What happens as this seemingly interminable spring rolls into a precarious summer? When will things go back to normal?
To hear more feature stories, get the Audm iPhone app. Read: How the pandemic will end
As I wrote last month, the only viable endgame is to play whack-a-mole with the coronavirus, suppressing it until a vaccine can be produced. With luck, that will take 18 to 24 months. During that time, new outbreaks will probably arise. Much about that period is unclear, but the dozens of experts whom I have interviewed agree that life as most people knew it cannot fully return. "I think people haven't understood that this isn't about the next couple of weeks," said Michael Osterholm, an infectious-disease epidemiologist at the University of Minnesota. "This is about the next two years."

The pandemic is not a hurricane or a wildfire. It is not comparable to Pearl Harbor or 9/11. Such disasters are confined in time and space. The SARS-CoV-2 virus will linger through the year and across the world. "Everyone wants to know when this will end," said Devi Sridhar, a public-health expert at the University of Edinburgh. "That's not the right question. The right question is: How do we continue?"

I. Reopening

A lockdown is a measure of last resort, to be used only when a virus is spreading so rapidly that it cannot be controlled through other means. Having deployed that measure, albeit unevenly, the U.S. has now bought itself some time. It can use that time to address its lack of tests and medical supplies, and find less economically devastating ways of controlling COVID-19. When sufficiently braced, states could begin lifting their sweeping restrictions and focus on finding and helping people who are actually infected. But the conditions for making that switch are not clear. "We've never faced a pandemic like this before in modern times, so we're going to have to be flexible," said Caitlin Rivers of the Johns Hopkins Center for Health Security. "There's no real playbook."

The White House seems to be relying heavily on one mathematical model from the University of Washington that, in its first incarnation, was criticized for failing to accurately predict death rates even a day or two out. (While traditional models simulate how a disease spreads through virtual communities, this one simply made predictions based on death numbers in the U.S. and death rates in other countries.) "When we make weather predictions or plan for hurricanes, we don't just plan based on one thing," said Natalie Dean, a statistician at the University of Florida. Alternative models are being built, but in the meantime, it's hard to accurately forecast how long the current phase of the pandemic will last.

Related Stories

Absent any certainty, one group of health experts, led by Ezekiel Emanuel, an oncologist and former adviser to the Obama administration, argues that stay-at-home orders must continue until at least May 20. Another team, led by Scott Gottlieb, a former FDA commissioner, suggests that states should relax their restrictions only after new case counts have fallen for 14 consecutive days. Currently, the U.S. is still averaging about 30,000 new confirmed cases every day. "My sense is that we haven't turned the corner," said Rivers, who is a co-author on Gottlieb's road map.

Both groups agree that before relaxing the guidelines on social distancing the U.S. urgently needs to expand its ability to test for the virus, and to shore up hospitals with sufficient supplies. These recommendations are sensible, but they hinge on the expectation that the U.S. can recover the ground it lost due to its early inaction. It might not be able to.

Read: Don't believe the COVID-19 models
For example, with help from private companies and academic institutions, the U.S. is certainly testing more people than it was before. Over the past week, about 145,000 people have been tested every day, according to the COVID Tracking Project, a volunteer collaboration spearheaded by The Atlantic. Those numbers look to rise even further, thanks to a new, rapid test from Abbott Laboratories that can deliver results in less than 15 minutes. But as testing capacity has grown, so has the pandemic. As my colleagues Robinson Meyer and Alexis Madrigal have reported, private labs have taken on more orders than they can fulfill, and are experiencing huge backlogs. Demand for tests has ballooned, fueled by a rise in actual infections and the fact that Donald Trump keeps wrongly assuring the public that testing is no longer a problem. "The net gain just hasn't been there," said Kelly Wroblewski of the Association of Public Health Laboratories.

Read: Private labs are fueling a new coronavirus testing crisis
Crucial medical drugs are also running out. According to a University of Minnesota analysis, about 40 percent of the 156 drugs that are essential parts of critical care are becoming limited. Many of these depend on supply chains that involve China (where the pandemic began), Italy (the hardest-hit region in Europe), or India (which halted several exports). These chains have been discharging their contents like a sputtering garden hose that has now begun to run dry. "The medium term is going to be particularly perilous," said Nada Sanders, a professor of supply-chain management at Northeastern University. "Global demand is so high, and supply is so far behind, that it's very hard to envision enough of a ramp-up."

Maya L. Harris: Some patients really need the drug that Trump keeps pushing
Meanwhile, hospitals are still struggling. There aren't enough masks and gowns to adequately protect staff, ventilators to deliver oxygen to patients who can't breathe, or respiratory technicians and nurses to operate those ventilators. Overwhelmed and underprotected, doctors and nurses are falling sick. In Michigan, more than 700 employees at one hospital have tested positive for the coronavirus; at another, 1,500 are out of work with consistent symptoms. Hospitals are now bringing back retired physicians, graduating medical students early, and re-tasking orthopedists and dermatologists to emergency rooms to help with the coronavirus surge.

Even if cases abate in the summer, exhausted health-care workers will have to catch up on elective surgeries that were postponed because of the pandemic (and that are important to a hospital's financial survival), while also treating people who delayed getting help for heart problems, cancers, and other emergencies. "Patients are putting off health concerns that really need to be seen, and they're coming in sick," Choo said. If the pandemic rebounds in the fall, health-care workers may have to greet it without having had a summertime respite. Hospital disaster plans "are all structured around a single discrete event that is over pretty quickly," Choo said. "We don't expect our diseases to be stuttering."

These problems-the continuing testing debacle, the drying supply chains, the relentless pressure on hospitals-should temper any impatience about reopening the country. There won't be an obvious moment when everything is under control and regular life can safely resume. Even after case counts and death rates fall, the pandemic's challenges will continue, and will not automatically subside on their own. After all, despite ample warning, the U.S. failed to anticipate what would happen when the coronavirus knocked on its door. It cannot afford to make that mistake again. Before the spring is over, it needs a plan for the summer and fall.

II. Recalibration

There's good reason to reopen the U.S. slowly and methodically. When the pandemic first hit, a wide range of social-distancing measures-closing offices, shutting schools, banning mass gatherings, implementing stay-at-home orders-were rolled out in a sudden panic. The rushed deployment was necessary, but made it hard to know which measures actually mattered. The next few months offer opportunities to find out. Communities could relax restrictions gradually, and see if the virus remains at a simmer or returns to a boil. When the virus returns, political leaders should be able to make more informed decisions about which levers to flip. "We should absolutely be throwing everything we can to figure that out," said Jessica Metcalf, an infectious-disease ecologist at Princeton.

The most crucial piece of missing information, and the one that most dramatically shapes the nation's options, is what proportion of people have actually been infected. So far, the U.S. has more than 576,000 confirmed cases. But between the lack of testing and the unknown proportion of people who experience mild or nonexistent symptoms, the true number of cases is anyone's guess.

There's an easy way to find out. When someone is infected, their immune system produces defensive molecules called antibodies, which recognize (and, with hope, neutralize) the virus. These antibodies endure after the infection is cleared, and should theoretically provide some degree of lasting immunity. By detecting such antibodies through what are known as serological tests, scientists can deduce how many people have been infected in these past months. (Serological tests differ from diagnostic tests, which search for pieces of the coronavirus's genetic material to work out who is infected right now.) Such "serosurveys" are ongoing, and while preliminary data have emerged, they don't paint a clear picture yet. In a German town that became a hot spot of the country's outbreak in February, about 15 percent of people have been infected; in a Colorado county, the figure stands between 0.4 and 1.5 percent.
Read: What you need to know about the coronavirus
If it turns out that, say, 20 percent of the U.S. has been infected, that would mean the coronavirus is more transmissible but less deadly than scientists think. It would also mean that a reasonable proportion of the country has some immunity. If that proportion could be slowly and safely raised to the level necessary for herd immunity-60 to 80 percent, depending on the virus's transmissibility-the U.S. might not need to wait for a vaccine. However, if just 1 to 5 percent of the population has been infected-the range that many researchers think is likelier-that would mean "this is a truly devastating virus, and we have built up no real population immunity," said Michael Mina, an epidemiologist and immunologist at Harvard. "Then we're in dire straits in terms of how to move forward."

Even in the optimistic scenario, a quick and complete return to normalcy would be ill-advised. And even in the pessimistic scenario, controlling future outbreaks should still be possible, but only through an immense public-health effort. Epidemiologists would need to run diagnostic tests on anyone with COVID-19-like symptoms, quarantine infected people, trace everyone those people had contact with in the previous week or so, and either quarantine those contacts or test them too. These are the standard pillars of public health, but they're complicated by the coronavirus's ability to spread for days before causing symptoms. Every infected person has a lot of potential contacts, and may have unknowingly infected many of them.

Tracking such a pathogen requires a lot of people, but due to chronic underfunding, local U.S. health departments lost more than 55,000 workers from 2008 to 2017. In their absence, a corps of volunteers could be quickly trained in the basics of contact tracing, as Massachusetts Governor Charlie Baker is planning to do. "It might be an opportunity to bring in people who are recently unemployed-a wartime effort where people aren't doing their normal jobs," said Crystal Watson of the Johns Hopkins Center for Health Security.
Read: The technology that could free America from quarantine

Once the U.S. gets better at tracking the coronavirus, it could use social distancing more flexibly and precisely. COVID-19 counts could feature on the nightly weather report, said Stephen Kissler, an infectious-disease modeler at Harvard. "In the same way that cities issue evacuation orders a few days before a hurricane hits, they could issue distancing orders a few days before we reach the threshold that would threaten to overwhelm our ICUs," he added.

There's a risk in trying to be too clever, though. Dylan Morris of Princeton, who also models infectious diseases, notes that exponentially growing epidemics are not just harder, but riskier, to control. Slight delays in action can have huge consequences, as the United Kingdom learned last month. Relying too heavily on models, the British government believed that it could precisely control the spread of COVID-19 by rolling out social restrictions at carefully chosen moments. Its hubris led to a substantial spike in cases. Now that the U.S. is slowing the pandemic, gently easing back on social distancing would be safer, Morris argues, than snapping back to business as usual when small missteps could be catastrophic. "If we're judicious about how we lift restrictions, we might never have to go back into lockdown," he said.
Read: The Four Possible Timelines for Life Returning to Normal
Stay-at-home orders might lift first, allowing friends and family to reunite. Small businesses could reopen with limitations: Offices might run on shifts and still rely heavily on teleworking, while restaurants and bars could create more space between tables. Schools could restart once researchers determine if children actually spread the virus.

This process might take several weeks to unfold, and even at the end of it, none of the experts I spoke with was comfortable with the return of crowded public spaces. Gottlieb's road map, for example, recommends that until a vaccine or an effective treatment is produced, social gatherings should be limited to 50 people or fewer. That will be especially challenging in large cities: An average Manhattan street or subway car is the equivalent of a mass gathering. Elsewhere, concerts, conferences, summer camps, political rallies, large weddings, and major sporting events may all have to be suspended for at least this year. "It's hard for me to imagine anyone going to Fenway Park and sitting with 30,000 fans-that will almost surely be a bad idea," said Ashish Jha, an internist and public-health expert at Harvard. "This isn't going to look like a normal summer in America."

III. Reinforcements

Read: The best hopes for a coronavirus drug
More realistically, treatments might give critically ill patients a better chance of survival, or prevent some people with early symptoms from ever needing critical care at all. Either would be an important win. "If people are feeling cruddy at home, and [an anti-COVID-19 drug] can reduce their risk of progressing to hospitalization from 20 percent to 10 percent, that would feel like a massive home run," Jha said.

First, antibodies aren't always effective at neutralizing viruses. If you picture the coronavirus as a car, an antibody might slash its tires, or just gum up its wipers-and simple serology tests can't tell which. Second, even if the antibodies are the right kind, no one knows what concentration you'd need to confer immunity. "Even for diseases we've been studying for over 100 years, like whooping cough, we still don't know what level of antibody would indicate that you'd be protected if you got reexposed," said Sam Scarpino of Northeastern University, who studies infectious-disease dynamics. The only way to find out is through long studies.

Third, serological tests for the new coronavirus could be deeply misleading for individuals. Consider the test produced by Cellex -the only one thus far with emergency use authorization from the FDA. The test has a 93.8 percent chance of correctly identifying people with antibodies against the new coronavirus, and a 95.6 percent chance of correctly identifying people who lack those antibodies. Those numbers sound great, but if only a minority of Americans have been infected, the test would return far more false positives than true ones. Put it this way: If you have a positive result, the odds that you actually have any relevant antibodies are roughly one in two if 5 percent of the U.S. has been infected, and just one in six if only 1 percent has been infected. Scientists can correct for these errors if they use serological tests to assess immunity in a population, but it's much harder on a person-by-person basis.

Finally, any certificate that affords special status, like the ability to work while others are quarantined, will create incentives for people to deliberately infect themselves or game the system with counterfeits. Immunity passports would unfairly "favor individuals who didn't comply with social distancing and got sick early on," said Alexandra Phelan of Georgetown University, who works on legal and policy issues related to infectious diseases. And "the idea that there would be a midpoint where some people could resume the right to be citizens and others could not is effectively an apartheid system," said Sharon Abramowitz, a consultant at UNICEF who studies community responses to pandemics. "It might serve specific public-health ends, but in this society would be very problematic." History affirms that concern: When yellow fever hit the American South in the 19th century, "immunoprivilege" worsened existing forms of discrimination while creating new ones.

Passports and antibody tests aside, it's reasonable to assume that someone who recovers from COVID-19 would be less likely to get infected again (for some duration that is still unclear). "But we can't assume that you won't bring that virus to someone else," said Mina, the Harvard immunologist. "I worry that a lot of employers are just assuming that having antibodies or having been infected means you're good to get back to work." A false sense of security could quicken the spread of the virus during future surges, especially if people ignore social-distancing orders on the mistaken belief that they are immune.

Read: The interminable body count
These problems might be surmountable. The U.S. is still a scientific and biomedical powerhouse. To marshal that power, it needs a massive, coordinated, government-led initiative to find the cleverest ways of controlling COVID-19-a modern-day Apollo program. No such program is afoot. Former Trump- and Obama-era officials have published detailed plans. Elizabeth Warren is on her third iteration. But the White House either has no strategy or has chosen not to disclose it.

That responsibility would typically fall to the Centers for Disease Control and Prevention, but it has been strangely silent. For almost a month, the CDC's leaders have been absent from press briefings, and its supporters fear that its reputation has been tarnished. Local leaders are making hundreds of public-health decisions-should we close this park, or open that beach?-without consulting the nation's top public-health agency. Jha said he regularly fields calls from mayors and governors who would normally ring the CDC. "People don't know where to turn to for expertise," he said.

IV. Resilience

During the Vietnam War, Vice Admiral James Stockdale spent seven years being tortured in a Hanoi prison. When asked about his experience, he noted that optimistic prison-mates eventually broke, as they passed one imagined deadline for release after another. Stockdale's strategy, instead, was to meld hope with realism-"the need for absolute, unwavering faith that you can prevail," as he put it, with "the discipline to begin by confronting the brutal facts, whatever they are."

The U.S. needs to learn that lesson, but Trump is still behaving as if he's engaged in a brief skirmish rather than a protracted siege. On April 8, before even the first pandemic peak had subsided, he tweeted: "Once we OPEN UP OUR GREAT COUNTRY, and it will be sooner rather than later, the horror of the Invisible Enemy, except for those that sadly lost a family member or friend, must be quickly forgotten." The enemy isn't going anywhere. To forget it would be to beget further horror.

Ibram X. Kendi: Stop blaming black people for dying of the coronavirus
Others will divert responsibility from the country's leaders and its institutions. "There's a lot of victim-blaming in the U.S., which comes from that neoliberal perspective where it's your fault if you have bad circumstances," said Emily Brunson, an anthropologist at Texas State University. The virus is disproportionately killing people in low-income jobs who don't have the privilege of working from home, but who will nonetheless be shamed for not distancing themselves. The virus is disproportionately killing black people, whose health had already been impoverished through centuries of structural racism, but who will nonetheless be personally blamed for their fate. The virus is disproportionately killing elderly people, who had already been shunted to the fringes of society, but who will nonetheless be told to endure further loneliness so that everyone else can be freer.

If that happens, the panic-neglect cycle will inevitably continue. The U.S. will miss the chance to reexamine how systemic failures of its health-care system left so many citizens vulnerable, or to put in place measures that might forestall another resurgence. It will get hammered by the same damn virus again, and be driven into more severe lockdowns. People will tire. Compliance will fall. The nation would lose its single most effective weapon against the pandemic-the willingness of its citizens to make individual sacrifices for the sake of all. It could forcibly quarantine uncooperative people or impose criminal penalties, but "we know from past outbreaks that criminalizing public-health responses makes people go underground, perpetuates stigma, and fractures society," Phelan said. "For the marathon we're facing, we need solidarity."

Over the coming months, we need "to normalize COVID in the public psyche, and reinforce that this will be a part of our day-to-day lives," said Kissler, the Harvard disease modeler. "Many people I've spoken with are aghast at the thought. We thirst for a swift and decisive 'victory.' But I'm reminded of images from World War II as people in London walked to work, briefcases in hand, against a backdrop of bombed-out buildings. I think we are in store for a similar period in history, as we learn to make greater peace with the world's chaos and our own mortality."

Shai Held: The staggering, heartless cruelty toward the elderly
This kind of psychological resilience already exists within large groups of people who have been marginalized during periods of normalcy, and who are now the most at-risk from the pandemic. Elderly people, for example, have been most frequently cast as a vulnerable group in need of protection. But "older people have been through a lot-the civil-rights movement, the women's movement, the Cold War," said Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security. "They are culture keepers, full of stories of how you get through major tragedies and upheavals."

The disability community has also noted that, at a time when their health is in jeopardy and their value is in question, abled people are struggling with a new normal that is their old normal-spatial confinement, unpredictable futures, social distance. "We know how to do community from afar, and how to organize from bed," said Ashley Shew of Virginia Tech, who studies the intersection between technology and disability. "Instead of feeling this great vacuum, our social life hasn't radically changed." Disability scholars have written about " crip time "-a flexible attitude toward timekeeping that comes from uncertainty. "Everything I enter in my calendar has an asterisk in my mind," Shew said. "Maybe it'll happen, maybe it won't, depending on my next cancer scan or what's happening in my body. I already live in this world when I'm measuring in shorter increments, when my future has always been planned differently."

As the rest of the U.S. comes to terms with the same restless impermanence, it must abandon the question When do we go back to normal? That outlook ignores the immense disparities in what different Americans experience as normal. It wastes the rare opportunity to reimagine what a fairer and less vulnerable society might look like. It glosses over the ongoing nature of the coronavirus threat. There is no going back. The only way out is through-past a turbulent spring, across an unusual summer, and into an unsettled year beyond.

Related Podcast

Listen to Ed Yong discuss this story on an episode of Social Distance, The Atlantic 's guide to the pandemic:

Subscribe to Social Distance on Apple Podcasts or Spotify (How to Listen)

* This article previously stated that Hong Kong and Taiwan were experiencing a resurgence of COVID-19 cases. In fact, both outbreaks appear to be stabilizing or declining, though it is too early to tell if this trend will hold.

Ed Yong is a staff writer at The Atlantic, where he covers science.

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The fight against the coronavirus won't be over when the U.S. reopens. Here's how the nation must prepare itself. Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here. Updated at 11:50 a.m. ET on April 15, 2020.

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So you want to wear a face mask? Good call.

A growing body of evidence supports the idea that wearing face masks in public, even when you feel well, can help curb the spread of the coronavirus - since people can spread the virus even without showing symptoms.That's the main reason to wear a mask: to protect other people from you.

Face masks can also offer the wearer some protection - though how much varies greatly, depending on the type of mask. No mask will offer full protection, and they should not be viewed as a replacement for physical distancing of at least 6 feet from others, frequent hand-washing and avoiding crowds. When you combine masks with those measures, they can make a big difference.

But what kind of mask is best?

When choosing a mask, experts say focus on the fabric, fit and breathability. How well a mask protects is a function of both what it's made of and how well it seals to your face. But if you can't breathe well through it, then you're less likely to keep it on.

Here's a look at different kinds of masks you might consider and how effective they are at protecting the people around you - and you as well.

Since the Centers for Disease Control and Prevention says people should wear cloth face coverings in public, we'll talk about fabric masks first. But if you've purchased a medical mask or respirator, scroll down for some important notes - like how to spot if you've got a fake.

Fabric Masks

First, consider the fabric itself. "The tightness of the weave is really important. That's the first thing I would ask people to look into," says Supratik Guha, a professor of molecular engineering at the University of Chicago. To check your fabric, hold it up to a light: If you can easily see the outline of the individual fibers, it's not going to make a great filter.

Researchers say a tight-weave 100% cotton is a good bet. That's because at the microscopic level, the natural fibers in cotton tend to have more three-dimensional structure than synthetic fibers, which are smoother, says Christopher Zangmeister, a researcher at the National Institute of Standards and Technology. That 3D structure can create more roadblocks that can stop an incoming particle, he explains.

Zangmeister co-authored a new study in ACS Nano that tested how well dozens of different materials filtered. While two synthetics, including one that's100% polyester, did well, most synthetics ranked near the bottom, he says. But even a mask made out of synthetic fibers is better than no mask at all, he says.

Think multiple layers. Several studies have found that masks made of multiple layers are more effective at blocking small particles.

A good option: a mask made of two layers of a tight-weave fabric with a built-in pocket where you can place a filter, says May Chu, an epidemiologist at the Colorado School of Public Health who co-authored a paper published on June 2 in Nano Letters on the filtration efficiency of household mask materials.

The best bet for the material to slip in as a filter is polypropylene, which is derived from plastic, says Chu. "If you go to Walmart, you look for Oly-fun, which is the brand name of that fabric. It's also called spunbond," says Chu, who's a scientific adviser to the World Health Organization and helped craft its recent detailed guidance on cloth masks.

Chu says polypropylene is great as a physical filter but has another benefit: It holds an electrostatic charge. In other words, it uses the power of static electricity. Think of the static cling that can happen when you rub two pieces of fabric together, says Chu. That's basically what's happening with this fabric: That "cling" effect traps incoming - and outgoing - droplets. "That's what you want - the cling is what's important," Chu says.

And unlike other materials, polypropylene keeps its electrostatic charge in the humidity created when you breathe out, says Yi Cui, a professor of materials science and engineering at Stanford University who co-authored the Nano Letters study with Chu.

Cui and Chu note that polypropylene will lose its electrostatic charge when you wash it, but you can recharge it by ironing it or by rubbing it with a plastic glove for around 20 seconds. Once you've got static cling, ka-ching - you're back in business. Cui says a two-layer tight-weave cotton mask alone can filter out about 35% of small particles. But adding a filter made out of two layers of charged polypropylene could boost that filtration efficiency by as much as another 35%, Cui says. You still want a cotton layer closest to your face, he says, because it's a more comfortable material.

If you can't get your hands on polypropylene fabric, reach for tissues: Take two sheets of facial tissue, fold them over and put them inside your mask's pocket so that you end up with a four-layer filter that you can change out daily. "Surprisingly, the four layers of paper gives you adequate protection," says Chu - though tissues don't have the added power of electrostatic charge.

If neither of those are options, a mask made of three or more layers of tightly woven cotton will also do a decent job, Chu says.

Though some sites online have suggested that coffee filters might make good mask filters, Chu and Zangmeister both advise against this. Zangmeister notes that coffee filters are hard to breathe through, so you end up breathing around the filter rather than through it.

"Imagine if you have a hose. You put your thumb over part of it, and the water just goes around it. In this case, the [air] flow will go around that filter," which defeats the purpose of using a filter, he explains.

Shape also matters: A mask's ability to filter out particles depends on not just what it's made out of but how well it seals to your face. When it comes to cloth masks, those that cup tightly to your face are best, Cui says. Masks with pleats or folds are also a good choice: The folds expand so that you have more air flowing through the fabric itself instead of leaking out through gaps at the sides of the mask. Masks with a flat front design are less effective, he says.

Another trick to improve the seal ofyour mask: Add a layer of pantyhose. Cut a length of hose about 8 to 10 inches long, from top to bottom, from one leg on a pair of hose, and pull it on top of your mask. This forces particles that might have otherwise gone around the loose edges of the mask and been inhaled to instead go through the mask, which can filter them out, says Loretta Fernandez, a researcher at Northeastern University.

What about neck-gaiter masks(also known as buffs)? Often made of synthetic fabric, they are designed to cover your face, nose and mouth and wrap around you. "There would theoretically be less chance for the air to escape laterally out of the sides like it would from a mask that's open on the side," says Dr. Abraar Karan, a physician at Harvard Medical School who's working on Massachusetts' COVID-19 response team.

Avoid masks with exhalation valves. Some cloth and disposable masks come with an exhalation valve at the front. The valve makes it easier to breathe out, but it also releases unfiltered air, so it doesn't protect others if you're contagious. And protecting others is the primary reason to wear a mask.

Keep it clean. Experts say cloth masks should be washed daily with soap or detergent and hot water. Make sure the mask is completely dry before you reuse it, as a wet mask can make it harder to breathe and can promote the growth of microorganisms.

Medical Masks

N95 respirators: N95 respirators are designed to create a tight seal around the nose and mouth. When worn correctly, they can block at least 95% of small airborne particles. These respirators are great at protecting both the wearer and the people around the wearer. One reason they're so effective: N95s are made out of many layers of fine polypropylene fibers, which, as we've discussed, use the power of static electricity to trap incoming and outgoing particles and droplets.

But experts say N95s remain in short supply and should still be reserved for health care workers and first responders. If you do get your hands on an N95, you should know that some of these respirators out thereare fakes. The Centers for Disease Control and Prevention has some tips on how to spot a counterfeit respirator.

KN95 respirators: A KN95 respirator is regulated by the Chinese government; like an N95, it's supposed to filter out at least 95% of small airborne particles. However, testing has revealed that the actual performance of many of the KN95s for sale in the U.S. "is all over the place," and many are counterfeit, says Avilash Cramer, a doctoral candidate at the Harvard-MIT Health Sciences and Technology program and a volunteer with PanFab, an effort to address shortages of medical devices and personal protective equipment amid the pandemic.

While some counterfeits may indeed filter out at least 95% of particles, "some are catastrophically bad. Some are falling apart in our hands," says Cramer, whose recent work with PanFab has focused on spotting and testing fake respirators. Trying to determine if a KN95 is counterfeit can be hard, he says, but here's one telltale sign: If the packaging says it's NIOSH approved, don't trust it - because a U.S. government agency like NIOSH (the National Institute for Occupational Safety and Health) would not approve a mask made to another country's standard. If you've got a KN95, Cramer says to check Appendix A of the Food and Drug Administration's emergency use authorization to see if the model you have is authorized.

Bottom line: If you have a KN95, just know it's possible you might not be getting nearly as much protection as you think. So be sure to keep up with those other habits to help keep you safe, including physical distancing. "Wearing even a genuine respirator doesn't make you invincible, so those habits are good no matter what," Cramer says.

Surgical masks: Surgical masks are disposable coverings worn loosely around the face. In short supply at the start of the pandemic, they're becoming more widely available. They're primarily designed to protect other people from the wearer and to block large particle droplets or splashes in the air, although not very small particles. Many surgical masks are made of paper, though some are made with polypropylene, says Lisa Brosseau, a research consultant with the University of Minnesota's Center for Infectious Disease Research and Policy. Research has found that surgical masks can block the vast majority of respiratory droplets emitted by an infected person. But how well a surgical mask protects you, the wearer, from smaller particles can vary widely when tested with the same methods used to test N95 respirators. For example, one surgical mask that Cui tested blocked around 30% of small particles, while others filtered out up to 80%.

Brosseau says she's seen some surgical masks that have been cleared for medical use by the FDA and have better filtration efficiencies, but most masks sold in the U.S. haven't gone through the FDA approval process.

Regardless of whether you choose a cloth or surgical mask, she says, be aware that this doesn't mean you can suddenly be in prolonged close contact with others. These masks might buy you a few extra minutes of protection, she says, but "not hours. Not lengthy periods of time."

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A User's Guide To Masks: What's Best At Protecting Others (And Yourself)

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So you want to wear a face mask? Good call. A growing body of evidence supports the idea that wearing face masks in public, even when you feel well, can help curb the spread of the coronavirus - since people can spread the virus even without showing symptoms.That's the main reason to wear a mask: to protect other people from you.

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7 Ways to Explore the Math of the Coronavirus Using The New York Times

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7 Ways to Explore the Math of the Coronavirus Using The New York Times

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The NY Times
Patrick Honner
April 2, 2020

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The daily news of the coronavirus is filled with mathematics: rates and data, charts and graphs, projections and probabilities. Mathematical and statistical literacy are fundamental to understanding our current crisis. Here are seven ways students and teachers can use New York Times resources to engage with the mathematics of the Covid-19 pandemic.

What's the point of social distancing? When will it be safe to return to normal? Using this Times interactive (scroll down in the Opinion piece to find the full model), students can play with various parameters of the pandemic and explore the consequences of government policies.

By using sliders to change, for example, the level of intervention (e.g., moderate or aggressive) or the length of intervention (e.g., 14 days or 60 days), students can see how outcomes change. And, by playing with the model, they will be able to answer questions like: "What is the impact of shortening our social distancing period?" or "What happens when we delay the start of our interventions?"

Students can also use the tool to dive deeper into more complex assignments, like determining when it's too late to start a mild intervention, studying how infectiousness changes both the height and the shape of the graph, or analyzing whether it's more effective for interventions to be aggressive or long.

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This article shares several interesting graphs depicting rates of change of coronavirus infections. "Growth Rates Over Time" (above) shows new infections per day in a selection of locations, allowing students to compare and contrast the spread of the virus in particular cities. Students can also grapple with a fundamental question of calculus by connecting how the graph of the rate of change of a quantity relates to the graph of the quantity. That is, what does the graph of new infections per day tell us about the graph of total infections?

"Growth Rate by Case Count" offers an exercise in advanced data literacy, as it graphs new infections against infections per capita instead against time. What does this graph tell us? How would we expect the rate of new infections to change as the number of infections per 1,000 people increases? When it comes to "flattening the curve," what would be a sign of success in this graph?

Any time we look at data related to rates of infection and transmission, we should make sure we understand the true nature of the data. This lesson on "dangerous numbers " is a place to start.

" How the Virus Got Out " details the dispersion of coronavirus across regions and the world, and in doing so brings ideas of elementary network theory into the analysis of the spread of the virus. Students can consider the role connectedness plays in the transmission of the virus: How much traffic exists between the different nodes of various regional and global networks, and how does this traffic combine with features of the virus, like its basic reproductive number and incubation period, to create a pandemic?

Students can also analyze this mobility data from the United States alongside case rates for Covid-19, the disease caused by the virus, and look for correlations. Will the path of the virus look different in places where people are moving around a lot compared with areas where people are staying put?

In response to the absence of a detailed government database of reported coronavirus cases, The New York Times has created its own coronavirus data repository. The easiest way to access this data is via The Times's continuously updated article " Coronavirus in the U.S.: Latest Map and Case Count." There you can study a map of where cases have been reported as well as compare the number of cases and deaths reported at the state and county level. You can also visit the New York Times GitHub page to collect data from every state and county in the United States. Where are the highest infection rates? Where are the lowest? Where is the disease spread starting to accelerate? And what are the underlying reasons for these numbers?

Students can use this data to track the spread of the virus in their home states and counties. They can compare and contrast conditions in regions of the United States, make their own data representations and project the possible course of the virus in their community based on what's happening elsewhere.

The number of people getting tested for coronavirus is another opportunity to exercise statistical literacy. The first graph in this article offers an opportunity to discuss the difference between measuring total tests administered and tests per capita. The United States seems to be ahead in total tests, but behind in tests per capita: Which one matters more when it comes to containing the spread of the coronavirus? If too few people are being tested, how does that shape our interpretation of the data of reported cases? The article also displays per capita testing rates for individual states, which students can use as part of a broader analysis of the data of Covid-19: How do your state's testing numbers compare with those of other states in your region? With the nation?

The Covid-19 pandemic is not the first epidemiological crisis the world has faced. This New York Times feature shares data and photos from flu pandemics in 1918 and 1968 as well as other infectious disease outbreaks. Students can study the epidemics of the past, and compare and contrast the current path of the coronavirus. For example, students can look at how countries are trying to "flatten the curve" of Covid-19, and compare those efforts with similar ones during the flu in 1918 (via National Geographic).

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7 Ways to Explore the Math of the Coronavirus Using The New York Times

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The daily news of the coronavirus is filled with mathematics: rates and data, charts and graphs, projections and probabilities. Mathematical and statistical literacy are fundamental to understanding our current crisis. Here are seven ways students and teachers can use New York Times resources to engage with the mathematics of the Covid-19 pandemic.

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Webinar: COVID-19 and Other Dangerous New Viral Diseases: Where do they come from? How can we fight them?

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Webinar: COVID-19 and Other Dangerous New Viral Diseases: Where do they come from? How can we fight them?

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Pearson Science
Joe Levine
March 30, 2020

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COVID-19 and Other Viral Diseases: Where do they come from? How can we fight them? - Fresh Ideas for Teaching

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As you continue to navigate your remote teaching and learning experiences we invite you to take a moment and join us for a special Pearson Science webinar to stay connected to the educator community and keep on learning. FREE WEBINAR: COVID-19 and Other Dangerous New Viral Diseases: Where do they come from?

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Webinar: Ask the Experts: Coronavirus Biology – Separating Fact from Fiction

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Webinar: Ask the Experts: Coronavirus Biology – Separating Fact from Fiction

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Drew University
Dr. Brianne Barker
March 16, 2020

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Ask the Experts: Coronavirus Biology – Separating Fact from Fiction

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Mathematical Models: Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve”

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Mathematical Models: Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve”

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The Washington Post
Harry Stevens

March 14, 2020

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Why It Only Took One Player With Coronavirus To Shutter Sports

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Why It Only Took One Player With Coronavirus To Shutter Sports

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FiveThirtyEight
Jared Dubin and Anna Wiederkehr
March 13, 2020

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After Utah Jazz center Rudy Gobert became the first athlete in American professional sports to publicly disclose a positive test result for the coronavirus (COVID-19), it took less than 24 hours for the rest of the sports world to come to a screeching halt.

Gobert's positive test was reported late Wednesday night, just about an hour after Utah's game against the Oklahoma City Thunder was originally set to tip off. By Thursday evening, the ripple effect was massive: in addition to the NBA, each of the NFL, MLS, NWSL, U.S. Soccer, ATP, MLB, NHL, NWHL, PGA and NCAA had canceled, suspended or postponed major events and/or the entirety of their league operations.

Though only one additional member of the 58 tested people associated with the Jazz (star guard Donovan Mitchell) tested positive for the virus, it's not at all difficult to see why the NBA had no choice but to suspend its operations immediately - and why other leagues had to do so as well. Even as teams play in different leagues, often in different cities and stadiums, American sports are highly interconnected, which underscores the need to take seriously how widely the virus can spread.

Recent research suggests that the virus transmits most easily through "prolonged, unprotected contact," so it's not particularly likely that the virus was transmitted to any of the players or employees of the teams against which the Jazz played, nor those who work in their respective arenas. But it is possible, so the utmost caution is warranted. That's especially true because while most professional athletes are not in the age range at risk of the most severe outcomes, many coaches, staffers and arena workers are. And the close quarters of athletic competition leaves people - players, coaches, executives, arena workers and fans alike - vulnerable to community spread.

"The problem is we don't know how many people have been infected in each location," said Wan Yang, a professor of epidemiology at Columbia University, about the risk of sporting events. "We've seen many, many cases of this superspreading due to huge gatherings. It's a big concern. If there's transmission locally, people getting together will lead to transmissions."

Accordingly, Gobert, Mitchell and the rest of Utah's traveling party have all been instructed to self-isolate for two weeks, as have any players who played against the Jazz within the 10 days prior to Gobert's positive test announcement, according to a report from ESPN's Brian Windhorst. But because the Centers for Disease Control and Prevention gives 14 days as the longest incubation period for similar viruses, teams like the Washington Wizards, who played the Jazz on Feb. 28, are also self-quarantining.

Within the 14-day period prior to Gobert's positive test, the Jazz also played games against the Boston Celtics (twice), Cleveland Cavaliers, New York Knicks, Detroit Pistons and Toronto Raptors, while Mitchell and the rest of Utah's traveling party also shared Chesapeake Energy Arena with the Thunder prior to the cancellation of Wednesday's game. And those opponents obviously didn't only play against the Jazz during that time span. Combined, Utah's seven scheduled opponents played against 12 other NBA teams; if any non-Jazz players unknowingly contracted the virus from Gobert and/or Mitchell, there is a chance they may have exposed those other teams to the virus as well. At the moment, no players on any of these teams have tested positive for coronavirus, and none has publicly reported experiencing symptoms; but because the onset of symptoms can sometimes be delayed, the safest course is self-quarantine.

But while no further coronavirus cases have been reported in the NBA, the potential effects of Gobert and Mitchell contracting the virus stretch beyond the league itself: The Jazz played three games in NBA arenas that are also home to NHL squads, and they played a home game against an NBA team that shares an arena with the NHL team in its city. The Knicks and Rangers both play in Madison Square Garden; the Celtics and Bruins both play in TD Garden; and the Pistons and Red Wings both play in Little Caesars Arena.

It seems unlikely that any of those hockey teams had direct contact with Gobert, Mitchell or anybody else from the Jazz's traveling party. But the virus can live on surfaces for days, and road teams in the NBA and NHL often use the same locker room in opposing arenas. That means the NHL teams that played in Boston, New York and Detroit in the days following the Jazz's visit to those cities and may have touched the same surfaces as either Gobert or Mitchell could conceivably be affected as well.

The Bruins played the Tampa Bay Lightning at home and the Philadelphia Flyers on the road in the days between the Jazz playing in their building and the announcement of Gobert's positive test. The Rangers played the Capitals and New Jersey Devils at home and the Dallas Stars and Colorado Avalanche on the road. And the Red Wings played host to both the Lightning and the Carolina Hurricanes.

That's 20 NBA teams and 10 NHL teams that have either been in at least one of the same arenas as the Jazz or played against a team that calls one of those arenas home during the period of time when Gobert and/or Mitchell may have already contracted the virus. Putting aside the relatively low probability of the virus spreading this way, the potential exposure of 30 of the 61 teams in two major sports leagues highlights exactly why games have been canceled for the foreseeable future.

Of course, all of these teams also participated in events beyond their games, including at locations beyond their home arenas, some of which also played host to other events. The Jazz held a practice at Emerson College in Boston, for example, though because the practice occurred during the school's spring break, the college has been advised that no immediate action is required. The Bruins' practice facility hosts home games for the NWHL's Boston Pride. The Wizards' practice facility was home to the Colonial Athletic Association's men's conference tournament, and the conference has announced that one of the game officials who worked at the men's tournament tested positive for the virus. Madison Square Garden was set to host the men's Big East Tournament before it was canceled on Thursday, though not before half of one game was played. Referees of Jazz games played both at home and on the road also traveled around the country to officiate other games.

The case of the Utah Jazz demonstrates why state and local governments in the U.S. continue to cancel mass gatherings, including sporting events. Doing so may help " flatten the curve " of the virus's spread, allowing the health care system to both delay and reduce the peak of the outbreak and potentially save the lives of people who may have otherwise become infected.

Why we shouldnâ€™t hope COVID-19 is seasonal like the flu

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Why It Only Took One Player With Coronavirus To Shutter Sports

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After Utah Jazz center Rudy Gobert became the first athlete in American professional sports to publicly disclose a positive test result for the coronavirus (COVID-19), it took less than 24 hours for the rest of the sports world to come to a screeching halt.

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Medium
Tomas Pueyo

March 10, 2020

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With everything that's happening about the Coronavirus, it might be very hard to make a decision of what to do today. Should you wait for more information? Do something today? What?

Here's what I'm going to cover in this article, with lots of charts, data and models with plenty of sources:

How many cases of coronavirus will there be in your area?

What will happen when these cases materialize?

What should you do?

When?

When you're done reading the article, this is what you'll take away:

The coronavirus is coming to you.
It's coming at an exponential speed: gradually, and then suddenly.
It's a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.

As a politician, community leader or business leader, you have the power and the responsibility to prevent this.

You might have fears today: What if I overreact? Will people laugh at me? Will they be angry at me? Will I look stupid? Won't it be better to wait for others to take steps first? Will I hurt the economy too much?

But in 2-4 weeks, when the entire world is in lockdown, when the few precious days of social distancing you will have enabled will have saved lives, people won't criticize you anymore: They will thank you for making the right decision.

Ok, let's do this.

Country Growth

The total number of cases grew exponentially until China contained it. But then, it leaked outside, and now it's a pandemic that nobody can stop.

As of today, this is mostly due to Italy, Iran and South Korea:

There are so many cases in South Korea, Italy and Iran that it's hard to see the rest of the countries, but let's zoom in on that corner at the bottom right.

There are dozens of countries with exponential growth rates. As of today, most of them are Western.

If you keep up with that type of growth rate for just a week, this is what you get:

If you want to understand what will happen, or how to prevent it, you need to look at the cases that have already gone through this: China, Eastern countries with SARS experience, and Italy.

This is one of the most important charts.

It shows in orange bars the daily official number of cases in the Hubei province: How many people were diagnosed that day.

The grey bars show the true daily coronavirus cases. The Chinese CDC found these by asking patients during the diagnostic when their symptoms started.

Crucially, these true cases weren't known at the time. We can only figure them out looking backwards: The authorities don't know that somebody just started having symptoms. They know when somebody goes to the doctor and gets diagnosed.

What this means is that the orange bars show you what authorities knew, and the grey ones what was really happening.

On January 21st, the number of new diagnosed cases (orange) is exploding: there are around 100 new cases. In reality, there were 1,500 new cases that day, growing exponentially. But the authorities didn't know that. What they knew was that suddenly there were 100 new cases of this new illness.

Two days later, authorities shut down Wuhan. At that point, the number of diagnosed daily new cases was ~400. Note that number: they made a decision to close the city with just 400 new cases in a day. In reality, there were 2,500 new cases that day, but they didn't know that.

The day after, another 15 cities in Hubei shut down.

Up until Jan 23rd, when Wuhan closes, you can look at the grey graph: it's growing exponentially. True cases were exploding. As soon as Wuhan shuts down, cases slow down. On Jan 24th, when another 15 cities shut down, the number of true cases (again, grey) grinds to a halt. Two days later, the maximum number of true cases was reached, and it has gone down ever since.

Note that the orange (official) cases were still growing exponentially: For 12 more days, it looked like this thing was still exploding. But it wasn't. It's just that the cases were getting stronger symptoms and going to the doctor more, and the system to identify them was stronger.

This concept of official and true cases is important. Let's keep it in mind for later.

The rest of regions in China were well coordinated by the central government, so they took immediate and drastic measures. This is the result:

Every flat line is a Chinese region with coronavirus cases. Each one had the potential to become exponential, but thanks to the measures happening just at the end of January, all of them stopped the virus before it could spread.

Meanwhile, South Korea, Italy and Iran had a full month to learn, but didn't. They started the same exponential growth of Hubei and passed every other Chinese region before the end of February.

Eastern Countries

South Korea cases have exploded, but have you wondered why Japan, Taiwan, Singapore, Thailand or Hong Kong haven't?

Taiwan didn't even make it to this graph because it didn't have the 50 cases threshold that I used.

Many of them were hit by SARS in 2003, and all of them learned from it. They learned how viral and lethal it could be, so they knew to take it seriously. That's why all of their graphs, despite starting to grow much earlier, still don't look like exponentials.

So far, we have stories of coronavirus exploding, governments realizing the threat, and containing them. For the rest of the countries, however, it's a completely different story.

Before I jump to them, a note about South Korea: The country is probably an outlier. The coronavirus was contained for the first 30 cases. Patient 31 was a super-spreader who passed it to thousands of other people. Because the virus spreads before people show symptoms, by the time the authorities realized the issue, the virus was out there. They're now paying the consequences of that one instance. Their containment efforts show, however: Italy has already passed it in numbers of cases, and Iran will pass it tomorrow (3/10/2020).

Washington State

You've already seen the growth in Western countries, and how bad forecasts of just one week look like. Now imagine that containment doesn't happen like in Wuhan or in other Eastern countries, and you get a colossal epidemic.

Let's look at a few cases, such as Washington State, the San Francisco Bay Area, Paris and Madrid.

Washington State is the US's Wuhan.The number of cases there is growing exponentially. It's currently at 140.

But something interesting happened early on. The death rate was through the roof. At some point, the state had 3 cases and one death.

We know from other places that the death rate of the coronavirus is anything between 0.5% and 5% (more on that later). How could the death rate be 33%?

It turned out that the virus had been spreading undetected for weeks. It's not like there were only 3 cases. It's that authorities only knew about 3, and one of them was dead because the more serious the condition, the more likely somebody is to be tested.

This is a bit like the orange and grey bars in China: Here they only knew about the orange bars (official cases) and they looked good: just 3. But in reality, there were hundreds, maybe thousands of true cases.

This is an issue: You only know the official cases, not the true ones. But you need to know the true ones. How can you estimate the true ones? It turns out, there's a couple of ways. And I have a model for both, so you can play with the numbers too ( direct link to copy of the model).

First, through deaths. If you have deaths in your region, you can use that to guess the number of true current cases. We know approximately how long it takes for that person to go from catching the virus to dying on average ( 17.3 days). That means the person who died on 2/29 in Washington State probably got infected around 2/12.

Then, you know the mortality rate. For this scenario, I'm using 1% (we'll discuss later the details). That means that, around 2/12, there were already around ~100 cases in the area (of which only one ended up in death 17.3 days later).

Now, use the average doubling time for the coronavirus (time it takes to double cases, on average). It's 6.2. That means that, in the 17 days it took this person to die, the cases had to multiply by ~8 (=2^(17/6)). That means that, if you are not diagnosing all cases, one death today means 800 true cases today.

Washington state has today 22 deaths. With that quick calculation, you get ~16,000 true coronavirus cases today. As many as the official cases in Italy and Iran combined.

If we look into the detail, we realize that 19 of these deaths were from one cluster, which might not have spread the virus widely. So if we consider those 19 deaths as one, the total deaths in the state is four. Updating the model with that number, we still get ~3,000 cases today.

This approach from Trevor Bedford looks at the viruses themselves and their mutations to assess the current case count.

The conclusion is that there are likely ~1,100 cases in Washington state right now.

None of these approaches are perfect, but they all point to the same message: We don't know the number of true cases, but it's much higher than the official one. It's not in the hundreds. It's in the thousands, maybe more.
San Francisco Bay Area
Until 3/8, the Bay Area didn't have any death. That made it hard to know how many true cases there were. Officially, there were 86 cases. But the US is vastly undertesting because it doesn't have enough kits. The country decided to create their own test kit, which turned out not to work.

These were the number of tests carried out in different countries by March 3rd:

Turkey, with no cases of coronavirus, had 10 times the testing per inhabitant than the US. The situation is not much better today, with ~8,000 tests performed in the US, which means ~4,000 people have been tested.

Here, you can just use a share of official cases to true cases. How to decide which one? For the Bay Area, they were testing everybody who had traveled or was in contact with a traveler, which means that they knew most of the travel-related cases, but none of the community spread cases. By having a sense of community spread vs. travel spread, you can know how many true cases there are.

I looked at that ratio for South Korea, which has great data. By the time they had 86 cases, the % of them from community spread was 86% (86 and 86% are a coincidence).

With that number, you can calculate the number of true cases. If the Bay Area has 86 cases today, it is likely that the true number is ~600.

France and Paris

France claims 1,400 cases today and 30 deaths. Using the two methods above, you can have a range of cases: between 24,000 and 140,000.

The true number of coronavirus cases in France today is likely to be between 24,000 and 140,000.

Let me repeat that: the number of true cases in France is likely to be between one and two orders or magnitude higher than it is officially reported.

Don't believe me? Let's look at the Wuhan graph again.

If you stack up the orange bars until 1/22, you get 444 cases. Now add up all the grey bars. They add up to ~12,000 cases. So when Wuhan thought it had 444 cases, it had 27 times more. If France thinks it has 1,400 cases, it might well have tens of thousands

The same math applies to Paris. With ~30 cases inside the city, the true number of cases is likely to be in the hundreds, maybe thousands. With 300 cases in the Ile-de-France region, the total cases in the region might already exceed tens of thousands.

Spain and Madrid

Spain has very similar numbers as France (1,200 cases vs. 1,400, and both have 30 deaths). That means the same rules are valid: Spain has probably upwards of 20k true cases already.

In the Comunidad de Madrid region, with 600 official cases and 17 deaths, the true number of cases is likely between 10,000 and 60,000.

If you read these data and tell yourself: " Impossible, this can't be true ", just think this: With this number of cases, Wuhan was already in lockdown.

With the number of cases we see today in countries like the US, Spain, France, Iran, Germany, Japan, Netherlands, Denmark, Sweden or Switzerland, Wuhan was already in lockdown.

And if you're telling yourself: " Well, Hubei is just one region ", let me remind you that it has nearly 60 million people, bigger than Spain and about the size of France.

So the coronavirus is already here. It's hidden, and it's growing exponentially.

What will happen in our countries when it hits? It's easy to know, because we already have several places where it's happening. The best examples are Hubei and Italy.

Fatality Rates

The World Health Organization (WHO) quotes 3.4% as the fatality rate (% people who contract the coronavirus and then die). This number is out of context so let me explain it.

It really depends on the country and the moment: between 0.6% in South Korea and 4.4% in Iran. So what is it? We can use a trick to figure it out.

The two ways you can calculate the fatality rate is Deaths/Total Cases and Death/Closed Cases. The first one is likely to be an underestimate, because lots of open cases can still end up in death. The second is an overestimate, because it's likely that deaths are closed quicker than recoveries.

What I did was look at how both evolve over time. Both of these numbers will converge to the same result once all cases are closed, so if you project past trends to the future, you can make a guess on what the final fatality rate will be.

This is what you see in the data. China's fatality rate is now between 3.6% and 6.1%. If you project that in the future, it looks like it converges towards ~3.8%-4%. This is double the current estimate, and 30 times worse than the flu.

It is made up of two completely different realities though: Hubei and the rest of China.

Hubei's fatality rate will probably converge towards 4.8%. Meanwhile, for the rest of China, it will likely converge to ~0.9%:

I also charted the numbers for Iran, Italy and South Korea, the only countries with enough deaths to make this somewhat relevant.

Iran's and Italy's Deaths / Total Cases are both converging towards the 3%-4% range. My guess is their numbers will end up around that figure too.

South Korea is the most interesting example, because these 2 numbers are completely disconnected: deaths / total cases is only 0.6%, but deaths / closed cases is a whopping 48%. My take on it is that a few unique things are happening there. First, they're testing everybody (with so many open cases, the death rate seems low), and leaving the cases open for longer (so they close cases quickly when the patient is dead). Second, they have a lot of hospital beds (see chart 17.b). There might also be other reasons we don't know. What is relevant is that deaths/cases has hovered around 0.5% since the beginning, suggesting it will stay there, likely heavily influenced by the healthcare system and crisis management.

The last relevant example is the Diamond Princess cruise: with 706 cases, 6 deaths and 100 recoveries, the fatality rate will be between 1% and 6.5%.

Note that the age distribution in each country will also have an impact: Since mortality is much higher for older people, countries with an aging population like Japan will be harder hit on average than younger countries like Nigeria. There are also weather factors, especially humidity and temperature, but it's still unclear how this will impact transmission and fatality rates.

This is what you can conclude:

Excluding these, countries that are prepared will see a fatality rate of ~0.5% (South Korea) to 0.9% (rest of China).

Countries that are overwhelmed will have a fatality rate between ~3%-5%

Put in another way: Countries that act fast can reduce the number of deaths by a factor of ten. And that's just counting the fatality rate. Acting fast also drastically reduces the cases, making this even more of a no-brainer.

Countries that act fast reduce the number of deaths at least by 10x.

So what does a country need to be prepared?

What Will Be the Pressure on the System

Around 20% of cases require hospitalization, 5% of cases require the Intensive Care Unit (ICU), and around 2.5% require very intensive help, with items such as ventilators or ECMO ( extra-corporeal oxygenation).

The problem is that items such as ventilators and ECMO can't be produced or bought easily. A few years ago, the US had a total of 250 ECMO machines, for example.

So if you suddenly have 100,000 people infected, many of them will want to go get tested. Around 20,000 will require hospitalization, 5,000 will need the ICU, and 1,000 will need machines that we don't have enough of today. And that's just with 100,000 cases.

That is without taking into account issues such as masks. A country like the US has only 1% of the masks it needs to cover the needs of its healthcare workers (12M N95, 30M surgical vs. 3.5B needed). If a lot of cases appear at once, there will be masks for only 2 weeks.

Countries like Japan, South Korea, Hong Kong or Singapore, as well as Chinese regions outside of Hubei, have been prepared and given the care that patients need.

But the rest of Western countries are rather going in the direction of Hubei and Italy. So what is happening there?

What an Overwhelmed Healthcare System Looks Like

The stories that happened in Hubei and those in Italy are starting to become eerily similar. Hubei built two hospitals in ten days, but even then, it was completely overwhelmed.

Both complained that patients inundated their hospitals. They had to be taken care of anywhere: in hallways, in waiting rooms...

I heavily recommend this short Twitter thread. It paints a pretty stark picture of Italy today

Healthcare workers spend hours in a single piece of protective gear, because there's not enough of them. As a result, they can't leave the infected areas for hours. When they do, they crumble, dehydrated and exhausted. Shifts don't exist anymore. People are driven back from retirement to cover needs. People who have no idea about nursing are trained overnight to fulfill critical roles. Everybody is on call, always.

Francesca Mangiatordi, an Italian nurse that crumbled in the middle of the war with the Coronavirus

That is, until they become sick. Which happens a lot, because they're in constant exposure to the virus, without enough protective gear. When that happens, they need to be in quarantine for 14 days, during which they can't help. Best case scenario, 2 weeks are lost. Worst case, they're dead.

The worst is in the ICUs, when patients need to share ventilators or ECMOs. These are in fact impossible to share, so the healthcare workers must determine what patient will use it. That really means, which one lives and which one dies.

"After a few days, we have to choose. [...] Not everyone can be intubated. We decide based on age and state of health." - Christian Salaroli, Italian MD.

Medical workers wear protective suits to attend to people sickened by the novel coronavirus, in the intensive care unit of a designated hospital in Wuhan, China, on Feb. 6. (China Daily/Reuters), via Washington Post

All of this is what drives a system to have a fatality rate of ~4% instead of ~0.5%. If you want your city or your country to be part of the 4%, don't do anything today.

Satellite images show Behesht Masoumeh cemetery in the Iranian city of Qom. Photograph: ©2020 Maxar Technologies. Via The Guardian and the The New York Times.

Flatten the Curve

This is a pandemic now. It can't be eliminated. But what we can do is reduce its impact.

Some countries have been exemplary at this. The best one is Taiwan, which is extremely connected with China and yet still has as of today fewer than 50 cases. This recent paper explain all the measures they took early on, which were focused on containment.

They have been able to contain it, but most countries lacked this expertise and didn't. Now, they're playing a different game: mitigation. They need to make this virus as inoffensive as possible.

If we reduce the infections as much as possible, our healthcare system will be able to handle cases much better, driving the fatality rate down. And, if we spread this over time, we will reach a point where the rest of society can be vaccinated, eliminating the risk altogether. So our goal is not to eliminate coronavirus contagions. It's to postpone them.

The more we postpone cases, the better the healthcare system can function, the lower the mortality rate, and the higher the share of the population that will be vaccinated before it gets infected.

How do we flatten the curve?

Social Distancing

There is one very simple thing that we can do and that works: social distancing.

If you go back to the Wuhan graph, you will remember that as soon as there was a lockdown, cases went down. That's because people didn't interact with each other, and the virus didn't spread.

The current scientific consensus is that this virus can be spread within 2 meters (6 feet) if somebody coughs. Otherwise, the droplets fall to the ground and don't infect you.

The worst infection then becomes through surfaces: The virus survives for up to 9 days on different surfaces such as metal, ceramics and plastics. That means things like doorknobs, tables, or elevator buttons can be terrible infection vectors.

The only way to truly reduce that is with social distancing: Keeping people home as much as possible, for as long as possible until this recedes.

This has already been proven in the past. Namely, in the 1918 flu pandemic.

Learnings from the 1918 Flu Pandemic

You can see how Philadelphia didn't act quickly, and had a massive peak in death rates. Compare that with St Louis, which did.

Then look at Denver, which enacted measures and then loosened them. They had a double peak, with the 2nd one higher than the first.

If you generalize, this is what you find:

This chart shows, for the 1918 flu in the US, how many more deaths there were per city depending on how fast measures were taken. For example, a city like St Louis took measures 6 days before Pittsburgh, and had less than half the deaths per citizen. On average, taking measures 20 days earlier halved the death rate.

Italy has finally figured this out. They first locked down Lombardy on Sunday, and one day later, on Monday, they realized their mistake and decided they had to lock down the entire country.

Hopefully, we will see results in the coming days. However, it will take one to two weeks to see. Remember the Wuhan graph: there was a delay of 12 days between the moment when the lockdown was announced and the moment when official cases (orange) started going down.

How Can Politicians Contribute to Social Distancing?

The question politicians are asking themselves today is not whether they should do something, but rather what's the appropriate action to take.

There are several stages to control an epidemic, starting with anticipation and ending with eradication. But it's too late for most options today. With this level of cases, the only options politicians have in front of them are containment, mitigation or suppression.
Containment
Containment is making sure all the cases are identified, controlled, and isolated. It's what Singapore, South Korea or Taiwan are doing so well: They very quickly limit people coming in, identify the sick, immediately isolate them, use heavy protective gear to protect their health workers, track all their contacts, quarantine them... This works extremely well when you're prepared and you do it early on, and don't need to grind your economy to a halt to make it happen.

I've already touted Taiwan's approach. But China's is good too. The lengths at which it went to contain the virus are mind-boggling. For example, they had up to 1,800 teams of 5 people each tracking every infected person, everybody they got interacted with, then everybody those people interacted with, and isolating the bunch. That's how they were able to contain the virus across a billion-people country.

This is not what Western countries have done. And now it's too late. The recent US announcement that most travel from Europe was banned is a containment measure for a country that has, as of today, 3 times the cases that Hubei had when it shut down, growing exponentially. How can we know if it's enough? It turns out, we can know by looking at the Wuhan travel ban.

This chart shows the impact that the Wuhan travel ban had delaying the epidemic. The bubble sizes show the number of daily cases. The top line shows the cases if nothing is done. The two other lines show the impact if 40% and 90% of travel is eliminated. This is a model created by epidemiologists, because we can't know for sure.

If you don't see much difference, you're right. It's very hard to see any change in the development of the epidemic.

Researchers estimate that, all in all, the Wuhan travel ban only delayed the spread in China by 3-5 days.

Now what did researchers think the impact of reducing transmission would be?

The top bloc is the same as the one you've seen before. The two other blocks show decreasing transmission rates. If the transmission rate goes down by 25% (through Social Distancing), it flattens the curve and delays the peak by a whole 14 weeks. Lower the transition rate by 50%, and you can't see the epidemic even starting within a quarter.

The US administration's ban on European travel is good: It has probably bought us a few hours, maybe a day or two. But not more. It is not enough. It's containment when what's needed is mitigation.

Once there are hundreds or thousands of cases growing in the population, preventing more from coming, tracking the existing ones and isolating their contacts isn't enough anymore. The next level is mitigation or suppression.
Mitigation or Suppression The new article, Coronavirus: The Hammer and the Dance, covers mitigation vs. suppression at length.
Mitigation requires a heavy amount of testing, contact tracing, quarantines and isolations to flatten the curve without stopping the outbreak

Suppression tries to go one step further and quench the outbreak. It requires heavy social distancing. People need to stop hanging out to drop the transmission rate (R), from the R=~2-3 that the virus follows without measures, to below 1, so that it eventually dies out.

These measures require closing companies, shops, mass transit, schools, enforcing lockdowns... The worse your situation, the worse the social distancing. The earlier you impose heavy measures, the less time you need to keep them, the easier it is to identify brewing cases, and the fewer people get infected.

This is what Wuhan had to do. This is what Italy was forced to accept. And then France, Spain, and many other countries. Because when the virus is rampant, the only measure is to lock down all the infected areas to stop spreading it at once.

With thousands of official cases - and tens of thousands of true ones - this is what countries like the US, the UK, Germany, Netherlands or Switzerland need to do.

But they're not doing it.

Some business are working from home, which is fantastic.
Some mass events are being stopped.
Some affected areas are in quarantining themselves.

Nobody can enter or exit lockdown areas, unless there are proven family or work reasons.

Movement inside the areas is to be avoided, unless they are justified for urgent personal or work reasons and can't be postponed.

People with symptoms (respiratory infection and fever) are "highly recommended" to remain home.

Standard time off for healthcare workers is suspended

Closure of all educational establishments (schools, universities...), gyms, museums, ski stations, cultural and social centers, swimming pools, and theaters.

Bars and restaurants have limited opening times from 6am to 6pm, with at least one meter (~3 feet) distance between people.

All pubs and clubs must close.

All commercial activity must keep a distance of one meter between customers. Those that can't make it happen must close. Temples can remain open as long as they can guarantee this distance.

Family and friends hospital visits are limited

Work meetings must be postponed. Work from home must be encouraged.

All sports events and competitions, public or private, are canceled. Important events can be held under closed doors.

All these measures will slow down the virus. They will lower the transmission rate from 2.5 to 2.2, maybe 2. Hopefully more. But they aren't enough to get us below 1 for a sustained period of time to stop the epidemic.

So the question becomes: What are the tradeoffs we could be making to lower the R? This is the menu that Italy has put in front of all of us:

Then two days later, they added: No, in fact, you need to close all businesses that aren't crucial. So now we're closing all commercial activities, offices, cafes and shops. Only transportation, pharmacies, groceries will remain open."

How to pick the right measures for your country? Read Coronavirus: The Hammer and the Dance. One approach is to gradually increase measures. Unfortunately, that gives precious time for the virus to spread. If you want to be safe, do it Wuhan style. People might complain now, but they'll thank you later.

How Can Business Leaders Contribute to Social Distancing?

If you're a business leader and you want to know what you should do, the best resource for you is Staying Home Club.

It is a list of social distancing policies that have been enacted by US tech companies-so far, 328.

They range from allowed to required Work From Home, and restricted visits, travel, or events.

There are more things that every company must determine, such as what to do with hourly workers, whether to keep the office open or not, how to conduct interviews, what to do with the cafeterias... If you want to know how my company, Course Hero, handled some of these, along with a model announcement to your employees, here is the one my company used ( view only version here).

It is very possible that so far you've agreed with everything I've said, and were just wondering since the beginning when to make each decision. Put in another way, what triggers should we have for each measure.

Risk-Based Model for Triggers

To solve this, I've created a model ( direct link to copy).

If your company had 100 employees in the Washington state area, which had 11 coronavirus deaths on 3/8, there was a 25% chance at least one of your employees was infected, and you should have closed immediately.

If your company had 250 employees mostly in the South Bay (San Mateo and Santa Clara counties, which together had 22 official cases on 3/8 and the true number was probably at least 54), by 3/9 you would have had ~2% chances to have at least one employee infected, and you should have closed your office too.

[Updated as of 3/12] If your company is in Paris (intramuros), and it has 250 employees, today there's a 95% chance that one of your employees has the coronavirus, and you should close your office by tomorrow.

It enables you to assess the likely number of cases in your area, the probability that your employees are already infected, how that evolves over time, and how that should tell you whether to remain open.

It tells us things like:

The model uses labels such as "company" and "employee", but the same model can be used for anything else: schools, mass transit... So if you have only 50 employees in Paris, but all of them are going to take the train, coming across thousands of other people, suddenly the likelihood that at least one of them will get infected is much higher and you should close your office immediately.

If you're still hesitating because nobody is showing symptoms, just realize 26% of contagions happen before there are symptoms.

Are You Part of a Group of Leaders?

This math is selfish. It looks at every company's risk individually, taking as much risk as we want until the inevitable hammer of the coronavirus closes our offices.

But if you're part of a league of business leaders or politicians, your calculations are not for just one company, but for the whole. The math becomes: What's the likelihood that any of our companies is infected? If you're a group of 50 companies of 250 employees on average, in the SF Bay Area, there's a 35% chance that at least one of the companies has an employee infected, and 97% chance that will be true next week. I added a tab in the model to play with that.

It might feel scary to make a decision today, but you shouldn't think about it this way.

This theoretical model shows different communities: one doesn't take social distancing measures, one takes them on Day n of an outbreak, the other one on Day n+1. All the numbers are completely fictitious (I chose them to resemble what happened in Hubei, with ~6k daily new cases at the worst). They're just there to illustrate how important a single day can be in something that grows exponentially. You can see that the one-day delay peaks later and higher, but then daily cases converge to zero.

But what about cumulative cases?

In this theoretical model that resembles loosely Hubei, waiting one more day creates 40% more cases! So, maybe, if the Hubei authorities had declared the lockdown on 1/22 instead of 1/23, they might have reduced the number of cases by a staggering 20k.

And remember, these are just cases. Mortality would be much higher, because not only would there be directly 40% more deaths. There would also be a much higher collapse of the healthcare system, leading to a mortality rate up to 10x higher as we saw before. So a one-day difference in social distancing measures can end exploding the number of deaths in your community by multiplying more cases and higher fatality rate.

This is an exponential threat. Every day counts. When you're delaying by a single day a decision, you're not contributing to a few cases maybe. There are probably hundreds or thousands of cases in your community already. Every day that there isn't social distancing, these cases grow exponentially.

This is probably the one time in the last decade that sharing an article might save lives. They need to understand this to avert a catastrophe. The moment to act is now.

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With everything that's happening about the Coronavirus, it might be very hard to make a decision of what to do today. Should you wait for more information? Do something today? What? Here's what I'm going to cover in this article, with lots of charts, data and models with plenty of sources: How many cases of coronavirus will there be in your area?

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As Schools Reopen, A New Tool Tracks Coronavirus Cases As They Emerge : Shots - Health News : NPR

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Looking for a snapshot of coronavirus outbreaks in U.S. schools? The National Education Association has just launched a tracker of cases in public K-12 schools.

The tracker is broken down by state and shows schools and counties with known cases and suspected cases and deaths, as well as whether those infected were students or staff. It also includes links to the local news reports so users know where the virus data comes from.

The NEA tracker builds on the volunteer efforts of a Kansas theater teacher Alisha Morris. In early August, just ahead of the new school year, Morris was looking for data about coronavirus cases in U.S. schools. She could find local news reports about positive cases at individual schools across the country but nothing that gave her a cohesive picture of how the virus was spreading in schools.

So Morris built it herself.

She started with a simple Internet search.

"I put in the words 'school, positive' " she tells NPR's Morning Edition. "I clicked on the news tab and would search the articles from the past week or the past 24 hours and then I would input those articles into my spreadsheet."

Morris started building a database on Aug. 6. She looked for news reports going back to July 1, since some schools had begun holding practices for fall sports or opening for administrative activities early in the summer.

Even with schools in only a few states back in session by early August, she had no trouble finding reports of coronavirus cases. Morris quickly logged cases at over 700 schools.

"I started feeling sort of shocked by what I was seeing and how many cases were already popping up in opening schools," she says. "That's when I decided that I should share it with some personal colleagues in Kansas and my district board of education. And their reactions are what really prompted me to share it on a wider scale with other teachers in the country."

By Aug. 23, when she handed off the project to NEA, she and volunteers working with her had logged over nearly 4,300 cases at more than 1,000 schools, which can be seen on the map above, created by one of the project volunteers.

According to the data she has collected, as of Aug. 23, Florida schools have seen the most cases, followed by Texas and Georgia. (The NEA is in the process of moving Morris' data to its tracker.)

Teachers began sharing Morris' database online. Soon, Morris started receiving submissions from viewers of the spreadsheet about cases she had missed. But she had to find a way to verify them: "I initially started with only putting information in that had to link with a local news article and the local news article was reporting from the quotes from the superintendent stating these certain things or similar things."

As she began to receive more submissions, Morris had to adapt her fact-checking process.

"People were actually submitting their own personal anecdotes about cases that hadn't been covered by the news," she says.

These submissions were sometimes screenshots of social media posts or parent emails sent by school administrators, which Morris believes are credible. She decided to create a dedicated section of the database for these kinds of reports, which she calls "unverified."

Morris and a small group of volunteers search for more information about those cases.

"We're still working on researching those unverified cases to see if articles pop up about them. But in the meantime, I've encouraged people to contact their local news outlets so that they can do some investigative journalism and see if they can find any affirmation that these cases were actually happening," she says.

And Morris believes that these unverified cases are an important piece of the puzzle.

"I absolutely get the suspicion based on the anecdotes that people have sent me, [that] there have been tons of schools that have been purposely trying to keep this on the down-low," she says.

She understands that schools are very worried about privacy, but, she says, "it does sort of create a bit of suspicion in the transparency. They will tell the close contacts and maybe the staff, but then they won't publicize it any further than that."

Finding a way to integrate these data into the project will give a better picture of how many elementary, middle and high schools are dealing with coronavirus outbreaks in the U.S.

Morris says she's relieved the NEA took note of the project and is hosting it. It has been hard keeping up with the cases, she says, and the NEA "has a team ready to go to keep the information up to date and to continue the community-driven efforts in order to get these cases logged."

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How Many Coronavirus Cases Are Happening In Schools? This Tracker Keeps Count

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Looking for a snapshot of coronavirus outbreaks in U.S. schools? The National Education Association has just launched a tracker of cases in public K-12 schools. The tracker is broken down by state and shows schools and counties with known cases and suspected cases and deaths, as well as whether those infected were students or staff.

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