We have been asking the wrong question as we consider dipping our toes into new activities during the coronavirus pandemic: Is it safe?
We are looking for a yes or no - a binary answer that harks back to our pre-pandemic lives. Instead, we should evaluate our encounters objectively based on some simple factors that place exposure on a risk spectrum. If we do, we will consolidate our successes and secure a clear path forward.
The idea that any activity is fully "safe" and carries zero risk of infection is a fantasy. We should turn away from that kind of thinking in order to have more honest and productive debate about how we restore some normalcy. Nothing is totally safe, but nothing guarantees infection either. There are risks to returning kids to school, and there are risks to keeping children isolated at home. We now live in a world of constant risk assessment and mitigation.
Oncologists like me are trained to evaluate risk factors and design treatments to reduce risk of cancer recurrence. In breast cancer, for instance, we evaluate various factors that increase the risk of tumor recurrence: size, lymph node involvement and other microscopic and molecular features. Each factor affects the overall recurrence risk, and if the collective risk exceeds standard thresholds, we recommend additional treatments to drive down the risk as low as possible. There is no magic to the science of curing cancer, there is only good risk assessment and escalation of aggressive treatment to minimize chance of recurrence.
We now have a public health consensus around the factors that increase the risk of coronavirus infection. Prolonged, crowded indoor unmasked face-to-face interaction seems to be the highest risk scenario and is almost always the setting of super-spreader events. On the other end of the spectrum, limited outdoor masked and distanced encounters appear to carry very low risk. Most of our day-to-day encounters fall in some messy intermediate. Despite the confusion, the inherent risk of any activity you can think up can be evaluated objectively based on these now well-defined risk factors.
We should all be asking what we can do in every interaction to shift the risk to the low end of the spectrum. Why are we having family over for dinner in the dining room when we could eat outdoors at a distance? Why are we not carrying a mask in our pocket when we leave home in case we encounter a situation where distancing is impossible?
This kind of vigilance exerts tremendous downward pressure on viral proliferation. Just like in cancer, there is no magic bullet. But we can prevent COVID-19 resurgence through multiple layers of risk mitigation. When used together, these measures collectively create an environment that is very inhospitable for viral transmission. In addition, widespread adoption of mitigation has a multiplier effect. For instance, even though a single mask is not 100% effective, the effect of 100% of the people wearing masks that are 60% effective likely approaches 100% containment of viral transmission. Unlike war, in public health, a herd working in unison with an imperfect tool is more potent than a fraction of people using a more sophisticated weapon.
But at the end of the day, the most powerful risk factor of coronavirus infection is prevalence of COVID-19 in the community. If the virus is not present, you can't get it. Likewise, in a COVID-19 intensive care unit with a smog of aerosolized virus, there is risk of infection even with the most aggressive mitigation available.
Through good governance and phenomenal public adherence to the guidelines, we in Connecticut drove the prevalence of this virus down into the ground. At the height of Connecticut's surge in late April, the 7-day average was 1,000 new cases per day. As of this writing, the 7-day average is 78 new cases per day. Further, Connecticut led the nation with the lowest rate of transmission four weeks running. The rate of transmission has hardly budged since we reopened the economy, evidence that people like you continue to behave responsibly after emerging from isolation.
Here, cases are low, and the few we have are being contained better than almost anywhere else in the country. Hospitalizations remain low, allowing the resumption of elective procedures. The percent of tests performed that result as positive hovers around 1%, an unthinkable statistic when back in April the rate exceeded 30% in the hardest hit areas. COVID-19 testing is now widely available at no cost, contact tracing is adequate, and we're developing novel techniques for early detection of outbreaks.
Is Connecticut safe? No. To say it is would be incomplete and misleading. Coronavirus is still bouncing around our communities, albeit at a very low rate. If we lifted mitigation strategies, cases would again exponentially rise. But with continued broad application of multiple risk mitigation strategies in the setting of low prevalence, we have pushed the risk of infection to the low and acceptable end of the spectrum. Connecticut is better positioned for continued success than almost any other state. The citizenry is informed and engaged, and our leadership is trustworthy and adaptable.
Because of our success, we now have an obligation to continue to forge ahead with intelligence and vigilance to draw a map for other states to find a safe way out of these woods.
ABOUT THE WRITER
David Grew, MD, MPH, is a radiation oncologist and a co-chair of the Cancer Committee at St. Francis Hospital in Hartford, Conn. He is promoting credible public health messaging on Instagram @davidgrew.
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