Covid is still very much with us, and will remain a significant public health problem for the foreseeable future. However, the Covid landscape has changed substantially over the nearly 4 years since it arrived. I recently spent some time reviewing and updating my assessment of my risk and my process for deciding what I am comfortable doing.
I will start with my understanding of my personal risks, which I divide into three categories: acute or short-term risks, chronic risk related to long Covid (PASC), and long-term risks from Covid’s impact on other disease processes.
The first question is: how likely am I to get infected?
My risk of getting infected is hard to quantify. Our public health systems and public policy made the inexplicable decision to assign responsibility for staying healthy to individuals rather than society and then stopped collecting and reporting key data like the frequency of new infections (incidence) or community prevalence and transmission. Some localities and smaller groups are still collecting and reporting this information, but it is piecemeal, often hard to scale or generalize, and not easy to find. I do what I can to reduce my risk of infection. I am fully vaccinated and keep up with boosters. I wear a good quality N95 mask (respiratory) consistently indoors in public places, and I avoid large indoor crowds of people whose behavior and health are unknown to me, However, my actual risk of being exposed to an infected and infectious person is impossible to know and hard to estimate. Based on a combination of wastewater surveillance and its relationship to community prevalence numbers, as of the beginning of December a rough estimate would be that ~ 1.8% of the US population is infectious (1 in every 54 individuals). This means that in a (random) group of 5 individuals there is roughly a 10% chance that someone in the group is infectious, and in a group of 20 (random) individuals, there is roughly a 30% chance that someone in the group is infectious. Wastewater surveillance indicates that case numbers are increasing in a roughly linear fashion such that by Christmas about 3% of the US population will be infectious and the likelihood of a group of 5 containing an infectious individual will be 15% and in a group of 20, about 50%. Obviously, there is a significant difference in risk of exposure related to different groups: a gathering of 10 of my 70+ year old cautious, mostly stay-at-home close friends does not present anywhere near the risk as a gathering of 10 random individuals on a Friday night in a bar with young and socially active partiers. The risk of being exposed and getting infected is small but not zero - or even inconsequential.
The second question is: what bad things might happen if I do get infected?
I see five categories of personal risk related to being infected with Covid:
1. Most obvious is the acute or short term risk of serious illness and death. The breathtaking success of the vaccine development program coupled with greater knowledge about treatment means that the current risk of severe infection requiring hospitalization, ventilatory failure, or death is now very low. The case fatality rate (CFR) has dropped by a factor of 10 since 2020 and is now only somewhat higher than the CFR for influenza. The current United States CFR for documented Covid is 4/1000 cases. This is a population number and not easily applied to an individual’s risk. Most (90%) of the deaths are in the elderly, very young, and those with significant medical issues. I am 76 but healthy so my personal risk of death if infected is probably closer to 8/1000 than 4/1000. That’s still a small number - but how many people would fly in an airplane if told their chance of a dying in a plane crash was 8/1000? One way to put this in context is to compare it with deaths from influenza - my risk of dying if infected with Covid is roughly 50% higher than my risk of dying if infected with influenza. Covid results in an additional 8 deaths/100 infected patients when compared to influenza and my risk of dying if infected with Covid is roughly 50% higher than my risk of dying if infected with influenza. And the risk of dying from other illnesses stays elevated for months after either an influenza or Covid infection.
2. Serious illness and death are not the only short-term risks, however. It is also quite disruptive, making one feel anywhere from mildly ill to quite ill for several days to several weeks. It commonly causes people to miss work, cancel appointments, stop socializing, find others to manage things like shopping, and cancel family plans.
3. Another - and more serious - risk of infection is long Covid (or PASC - post acute sequelae of Covid). Although this can be devastating (and there are far too many among us whose lives have been ruined by this) there is good news here. The risk of experiencing long Covid has been steadily decreasing since 2020 and (barring changes from a new variant with different biologic behavior) it will continue to decrease. Some of this is related to changes in the circulating variant, but most of it appears to be related to a population with significant immunity related to a combination of vaccination and infection, (The evidence tells us that immunity from vaccination is both more effective and longer lasting than immunity from infection alone.) We know that the risk of long Covid is related (albeit imperfectly) to the severity of the initial infection. Vaccines have been truly miraculous in this respect. The data is fuzzy, but a good estimate is that the risk of long Covid after a first infection was ~ more than 10% in the first half of 2020, had dropped to ~ 3% by the end of 2021, and is now < 2%. It also is clear that, although there is additional risk with each additional infection, the additional risk is much smaller. For example, the risk of long Covid after a second infection is only 30% of the risk after an initial infection. And immunization appears to reduce the risk of long Covid by at least 70%.
4. A fourth personal risk of infection is the increase in long-term morbidity (illness) and mortality (death) from causes other than Covid. We know that the risk of many serious illnesses is increased after Covid: thromboembolic diseases (related to clotting), heart attacks, strokes, cardia rhythm disorders, autonomic nervous system problems (POTS), dementia, autoimmune diseases, and neurologic disorders. We don’t yet know how long this increased risk persists.This should not surprise us, as this is known to occur with other viral infections including influenza - though to a much lower degree. The additional depth and breadth of this risk is probably related to the fact that Covid is a systemic-vascular illness while influenza is largely limited to a pulmonary illness.
5. Finally, there is the still largely unknown and unknowable risk of truly long-term events, something seen in a wide ranging group of viral illnesses. Measles and subacute sclerosing panencephalitis or SSPE, the 1918 influenza outbreak and a subsequent (20 years later) surge in Parkinson’s Disease, human herpes virus 4 which causes infectious mononucleosis is associated with Hodgkin lymphoma, nasopharyngeal carcinoma, and is the probable culprit in most cases of multiple sclerosis, chickenpox and shingles, human papilloma virus (HPV) and genital/oral/anal cancers, post polio syndrome, HIV and AIDS. There is some evidence that Norovirus is associated with later development of Crohn’s disease. This is also true of some bacterial infections: streptococcus leading to glomerulonephritis and rheumatic heart disease and Lyme leading to ME/CFS. These are risks it will take decades to recognize and quantify.
My personal risk is not my only consideration.
No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were. Any man’s death diminishes me, because I am involved in mankind.
(John Donne)
If I become infected and am infectious, there are potential impacts on my family, friends, community, and on society as a whole;
1. I might infect others and they might suffer any of the spectrum of mild through fatal consequences discussed above. To make things more complicated, I might be unaware that I am infected and infectious.
2. In addition to infecting other individuals, if I am infected and infectious I will be contributing to community transmission and thereby increasing the risk to others when they do either necessary things (shopping, going to work, going to school, getting care at a medical office) or social things. Or just living in a nursing home.
3. And, if I talk and act (as suggested by our public health policy) based only on my assessment of my own personal risks and priorities, then I am contributing to the devastating trend in our culture of abandoning any interest in the common good and replacing ‘we’ with ‘me’ in all our policies and norms. Though this is the least concrete of the issues I’ve discussed here, it is arguably the most consequential.
If you’ve read this far you may be expecting a simple formula or set of rules for how to navigate Covid at the end of 2023 and beyond. I suspect you will be disappointed and frustrated by what I have to say:
• I try to avoid indoor gatherings of people whose health and behavior are unknown to me. Eighteen months ago, this sentence would not have started with “I try to” but was a pretty absolute policy. This is a change for me and I struggle to be comfortable with it after several years of being pretty strict.)
• I consistently use a good quality N95 respiratory (mask) with indoor gatherings and public places (shopping, transportation, committee meetings…). The exception is with small groups whom I know well, or if everyone agrees to test. (Yes, I know that testing is not perfect. The perfect should never be the enemy of the good.)
• I have a good quality CO2 meter (aranet4) which I bring to all indoor events to assess ventilation. If it stays under 800 ppm of CO2, I am pretty comfortable. If it goes much over 1000 ppm CO2 I leave if at all possible.
• I do what I can to maximize both ventilation and filtration when I am indoors with others. In public, I sit as close as possible to a door or open (one hopes) window. At home, this involves opening doors or windows. I live in Maine but one can still open a window (or two) 1/2 inch to increase fresh air in a room when others gather. I have two DIY Corsi-Rosenthal boxes I use at home when guests come. I occasionally take them with me to other events. (It gives me a chance to proselytize for clean air.)
• I test before I attend indoor gatherings of people who may be at increased risk or have individuals at increased risk in their social circle.
• I plan to continue to update my vaccination status as newer vaccines or boosters become available. (Using my seatbelt last year doesn’t help me this year.)
• I will continue to do as much as my time and energy allows to provide others with accurate, updated, and actionable information. This includes responding when misinformation is out there, not because I think it will change the misinformer (many are pretty locked into a world view that is more dogma than science) but because it is important not to let the falsehoods or poor analyses stand unchallenged.
• I will continue to dream of a society where ‘we’ becomes more important than ‘me’ and where people are willing to get vaccinated, mask indoors, and test or stay home with symptoms; where public policy and resources prioritize PUBLIC health rather than private decision making and work to ensure transparent and accurate information (including tracking and reporting on health matters) and working to ensure safe air the way we ensure safe water.
I hope this has been helpful to those reading it. The work of thinking it through and committing it to a public post was useful for me.
Stay safe and be well. The health you save may be your own - or that of someone you live.