• PublicHealthRising

Time to Up Your Game

The rules are changing and you need better defensive equipment.

COVID-19 is not loosening its grip. Where vaccination coverage remains low, either due to inequitable supply or lack of demand, it remains an all-encompassing threat. Where vaccination coverage is higher, the pressure can be hit-or-miss, and it can be hard to tell when a hit might be coming. Rather than the rollercoaster we’ve talked about before -- we were all on that ride together -- the delta variant requires intensive efforts to control, and a bit of vaccine here and a few public health measures there just doesn’t cut it. Now there are a lot more individual choices to make about how to protect yourself. It’s like a terrible game of dodgeball, and this is how it works for many of us:

  • There are a bunch of balls flying through the air; you need to avoid getting hit. The balls are invisible.

  • You may have some protective equipment, so depending on where you get hit you might be able to continue playing. In some cases the ball might bounce off you and hit someone else, who has no protection.

  • You can collect more protective equipment, but you’re an ethical competitor and you’re not sure if taking more for yourself will deny protection to others.

  • You have to stay on the playing field, which means venturing out to work, to school, etc.

This battle with COVID is an individual sport: you don’t have team-mates to lean on as you tire out while the game wears on (and we still don’t know how much time is left on the clock). The aim is to avoid getting hammered by COVID-19. This might mean avoiding severe illness if you’re a healthy adult, or avoiding infection altogether if you’re in much younger or much older age brackets. There is no way to score points yet -- there is no offense in this game, just defense. The idea that the pandemic can be attacked and defeated is a trap; there is no offensive playbook. That’s the main key to survival: a defensive mindset. Get a read on what the opposition is doing and reposition quickly to offset whatever attacks are thrown at you.

So how do you scan the playing field to assess what’s coming at you? A few options:

  • COVID infection rates in your community: CDC risk guidance is both complicated and outdated, having been developed with pre-delta data. To get a quick sense: an infection rate above 10 new cases per 100,000 population and/or an increasing trend in infections means you may need to solidify your defense. For the most information at a glance, from global to national to state and county, we like the STAT tracker.

  • Masking around you: There’s not a great data source out there, and in any case you want to know how people are masking: good fit, good material? If you see good masks aren’t being used consistently and correctly, get ready to dodge some balls.

  • The air you’re breathing: You need a lot of dilution or a lot of filtration to defend yourself. CDC has vague guidance and still hasn’t embraced the need to reduce aerosol transmission. The conventional wisdom of aiming for 4-6 ACH (air changes per hour) is really not actionable or measurable in most settings, but the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) has a very practical guide to layering your defense. This is something you can bring to your school districts and principals.

  • Vaccination coverage in your community: Important, but a difficult indicator to rely upon for guidance. This is both because there are (seemingly rare, but rate unknown) instances of vaccinated people transmitting COVID, and because vaccination is not evenly distributed in a community. If your county, for example, has 70% of people fully vaccinated (and an initial dose does not count against delta), depending on your social circle and neighborhood, you might be mingling with people who are mostly vaccinated, or mostly not. Coverage rates may also vary widely by age, with older adults establishing very high coverage while well less than half of younger people may be vaccinated. You can explore more on your own state or county websites, or take a look at CDC maps.

From the information you collect, you can set up your defensive position and your protective equipment. Start with better masks: this will be our third time since January (Loose Lips Lose Lives) emphasizing how important this is -- and in fact it’s more important now than it ever has been for kids under 12 who can’t yet receive a COVID vaccine. Short of an N95 respirator that fits smaller faces, a few good options for kids are KF94 masks and KN95 masks. There are many other standards and mask ratings out there, and it’s possible to find other good options. It’s also possible to easily take a wrong turn (e.g. you might see, and want to avoid, ASTM classifications. These are mainly based on materials, not fit or actual effectiveness in respiratory protection). And you do need to watch out for counterfeits. To get you and your family masked up:

(1) Find a KF94 or KN95 mask for sale; if you start with a trusted vendor, like the non-profit Project N95, you don’t need to worry about counterfeits;

(2) Look for a size that fits; there is some great sizing information here (although we couldn’t vouch for the filtration results);

(3) Avoid counterfeits if you can, by checking the CDC list or trying to buy from Korean manufacturers listed here (use the language translator in your web browser) -- if the product is listed the Koren government is providing some assurance it’s not a counterfeit;

(4) Check that your mask seals around your mouth and nose, which you can assess by breathing in through your mouth and seeing the mask pull in towards your face, which typically wouldn’t occur if there was a significant leak. A real at-home fit-test is also possible. Note that fit-testing is often based on taste (bitter or sweet); all the comparisons you might be hearing between aerosol viruses and cigarette smoke could be misleading. Although smoke particle size can vary widely, and some smoke particles are in the same range of size as COVID virus particles (0.1 micrometer, or um, and larger), cigarette smoke particles can be measured in nanometers, or nm -- a unit that is 1,000 times smaller than a micrometer. If you can smell cigarette smoke through your N95, KN95, or KF94 mask: check for leaks, but consider that this doesn’t mean the mask is ineffective against COVID.

After you get your mask sorted out, get some air. Access to fresh air or highly filtered air is a key play. CDC’s failure to embrace aerosol transmission continues, as reflected in their current school guidance, which still puts 3 feet of distance as a higher priority than ventilation, which they don’t even attempt to quantify. This remains inexplicable, and just like for “masking,” the concept of “ventilation” needs to be tackled in some detail -- how you do it really matters. If you’ve seen a recent small study of a single classroom outbreak, you’ll see that we’re not masking right, and we’re not ventilating right. In the meantime, start working in that direction: for example, if you have a kid in a classroom where the district has not emphasized ventilation, build and deliver a box fan air cleaner. If you click on that link, you’ll see (in addition to learning how to build the thing) that, just like for masks, the details are critical. This includes the number of units to use (more are not necessarily better) and where the unit is placed (typically needs to be near the existing ventilation system). With a good mix of air, maybe some of the invisible dodgeballs will sail over your head and out the window.

Your final piece of defensive equipment to consider are vaccines. This is fairly straightforward, although there are some questions we’ve heard about bending age requirements. For an 11 year old who is just starting school and soon to turn 12, it would be reasonable to try and start the vaccination series as soon as possible. For younger kids, better to wait until ongoing studies have been completed, as a different profile of vaccine dosages and side effects could emerge. Vaccines get more complicated around additional doses and global equity issues. First, the justification for an additional dose varies. For elderly, frail, and otherwise ill people (for example, with immune suppression) this additional dose is likely required, and perhaps should not even be considered a “booster” dose. It’s really the completion of the primary immunization series, for effective protection against severe illness, hospitalization, and death. For others, an additional dose falls into more of a grey area at the moment. The uncertainty here is what an additional dose provides, in context of most of the rest of the world remaining without even a single dose. For otherwise healthy individuals, an individual dose may most likely result in asymptomatic or minimally symptomatic infection, as compared to symptomatic but still not severe illness that seems to be the predominant manifestation of infection among vaccinated people. If there were a clear benefit in reducing infection or transmission, that might indicate some increased societal benefit as well. But our overall societal benefit will remain most limited by the many who continue to remain completely unvaccinated.

For those of us who do not need an extra dose to complete our initial vaccination series: Looking back at the rules of the “game,” you can collect more protective equipment, but you’re an ethical competitor and you’re not sure if taking more for yourself will deny protection to others. So, is it fair to get an additional dose? Maybe, if you imagine the U.S. can more aggressively support global health efforts if domestic COVID is well controlled. This is the equivalent of the airplane safety advice, “put your own oxygen mask on first” before helping others. Or maybe not, if you imagine that most of the U.S. has a life jacket, and the extra dose is an extra that could be thrown to drowning people. Your decision will be based on your individual situation, your interactions with vulnerable people. If you get a booster, consider taking one action to push vaccines around the world: a call/letter to a member of Congress and support to organizations like Unicef that are working for fair and equal access to vaccines and asking G7 nations to #DonateDosesNow, or IRC which is working to directly vaccinate high risk populations globally. And keep yourself informed about the stark inequities in global distribution.

Ultimately, of course, it’s not a game. The consequences of “losing” are not fully predictable. While a sports metaphor runs the risk of minimizing the impact of infection, disability, and death, we hope that this framing provides a better way to picture risk in your environment, and some of the steps you can take to defend yourself and your family. And in the end, defense does win games.

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