COVID-19 Risk Reduction: Livable Rules to Decrease Transmission


This is hard. Really hard. As a physician, I take COVID-19 very seriously, and have found myself with friends and family being in the position of the “rule-following bad guy”. I’m the one insisting on not being in the same car with friends driving to an outdoor activity, I’m the one not hugging or shaking hands, I’m the one who won’t let my son play with his best friend because the friend’s family has had out of state visitors who have not quarantined. We have all recently found ourselves navigating the reopening of friendships, school, work, travel, and business amid the pandemic.

COVID-19As case numbers climb, and states continue to open, the challenge of staying safe and learning how to accurately evaluate risks in order to figure out COVID-19 risk reduction for ourselves and our families is going to be the key to making it through the next chapter.

The risk of coronavirus remains real and there is no end in sight. But work and school are reopening, and many friends may feel comfortable going to bars and restaurants or having parties. Out of staters from states with continued high numbers of COVID-19 cases may want to visit, or you may want to visit them.

How do we figure out what level of COVID-19 risk is ok and what isn’t?

The concept of risk reduction can be borrowed from many public health campaigns including opioid overdoses and the fight against HIV/AIDS. The idea is one that the individual accepts SOME risk, but tries to minimize that risk by avoiding activities that are more dangerous while engaging in activities that are less dangerous. Deciding what activities you do and don’t want to engage in requires understanding of how the virus spreads, higher and lower risk activities, as well as a clear understanding of the risk factors for severe disease you or members of your family unit or household have.

By now we are familiar with the concept of family units- those people who share a home with you, or possibly even limited numbers of people you are around without using a mask or social distancing from each other. These may include significant others, adult children, grandparents, childcare providers, etc. They are in our ‘bubble”.

What one of these people does, the rest assume contagious risk for. This is to say, all members of a bubble must agree to follow the same safety guidelines.

These are people who you need to know well, trust, and have frequent check-ins with around each other’s activities. Do they share a similar value system to you around risk reduction? Are they following similar rules and guidelines? The answers to these questions may change over time as COVID-19 fatigue sets in, so going over the ground rules of the relationships frequently is important.

Once we start interacting with those outside of our bubble, our potential risk for getting infected with coronavirus starts increasing. In some cases, it increases slightly, and in others, exponentially. This differentiation is the key to making choices that involve the process of COVID-19 risk reduction to reduce the spread of COVID-19.

In addition to evaluating the risk of activities, we also need to evaluate our own personal risk (and that of anyone in our bubble) for bad outcomes.

The higher your risk factors (or those of your loved ones) are, the less risk tolerance you should have.

Risk factors including age (infants and people over 60 are higher risk), obesity, diabetes, cancer, and immune compromise top the list for factors that are associated with greater COVID-19 mortality.

baby feet, infant feet, hospital bracelet, newborn baby feet, baby toesWe also need to differentiate between mortality (death) and morbidity (the degree to which people get REALLY REALLY SICK even requiring long ICU stays and intubation). The risk factors we all hear about are for MORTALITY. They have nothing to do with morbidity. In other words, young, healthy people are commonly getting really sick and needing prolonged ICU care, but because they are young and healthy to start, they are less likely to die. You do not see these numbers in the death statistics. You only see them in the hospitalization and ICU statistics.

In order to understand what is safe and what isn’t, you need to understand a bit about how the virus is spread. This has been a bit of a difficult thing to understand because this virus is new, and at the start of the pandemic, we didn’t understand as much about it as we do now.

We now know that the virus can spread both by droplets and by airborne spread.

respiratory dropletsThe likelihood of getting infected is proportional to how many viral particles you inhale. This is a function of the concentration of viral particles around you, the distance you are from the source of infection, as well as the time spent in the environment containing those particles. Understanding these simple facts will give you a lot of information that can be used as a common-sense evaluation tool for activities, and ultimately for COVID-19 risk reduction.

In other words, the factors that we look at to determine how dangerous an activity is, are:

  1. Time, or length of potential exposure, because more time equals more risk.
  2. Space, or is this activity inside or outside? Indoor activities are more dangerous than outside activities.
  3. Crowdedness, or are you in an area with many people, which is riskier than being in an area with fewer people.
  4. Force of exhalation. This means that someone blowing out candles and singing Happy Birthday is riskier than time spent in a library.
By Ezekiel J. Emanuel

Fortunately, we can use length of time, space, crowdedness, and force of exhalation of potential exposure to better understand our risk of contracting COVID-19 in any given situation. These risk factors allow us to make choices about what risks we decide to take and to reduce those risks. COVID-19 risk reduction is a tool we can all use, once we understand it.

The first and biggest step we can take is to wear a mask.

Wearing a cloth mask decreases the number of viral particles in droplet form that you spread from your nose and mouth and helps protect those around you from YOU. It may also cut the infectivity to you depending on the number of layers of material the mask has. Wearing a mask when indoors or in close quarters is the right thing to do for our society to keep the spread of the disease lower and thereby keep people healthy AND keep the economy in better shape.

woman in maskAvoid indoor venues that are crowded with other people, when you can.

The less crowded the space, the better. The further you stay from others, the better. The less aerosolizing of body fluids the better- which means indoor places that have a lot of people yelling or singing are high-risk places. These places include bars, indoor seating at restaurants, sporting events, church, choir, concerts, movies, theater, weddings, public transportation, air travel, etc.. If you are going to do any of these things or allow anyone in your bubble to do them, you should really be asking yourself if it is important enough for you or a loved one to die for.

Regarding the above more dangerous activities, the more TIME you spend in the environment, the higher the risk of transmission to you.

So sitting next to an infected person on a plane for 6 hours is worse than walking past an infected person at the grocery store. Grocery store clerks are at higher risk than grocery store patrons due to the length of their potential exposure- given that they remain in an indoor, crowded space all day and have lots of contact with many different people.

Activities that are relatively low risk include activities that occur outside with appropriate social distance. Taking a walk or hike or bike ride with a few friends, a small outdoor dinner gathering, public places like beaches or parks with appropriate social distancing (six feet minimum) are all relatively low risk.

The virus most likely does not survive alive and in an infective state for long on surfaces, activities like going to the grocery store (assuming you and others are masked and maintain social distance) is relatively safe. You do not need to decontaminate your groceries when you bring them home. Frequent hand washing is still a good idea, but the practice of using gloves has NO UTILITY in preventing transmission. Please stop using disposable rubber gloves and just wash or sanitize your hands after shopping or spending time touching things the public has touched.

Using alcohol and other drugs is a high-risk activity because these substances impair your judgment and inhibitions and make you less likely to notice if you are maintaining proper distance and less likely to remember to wear your mask properly. This is why we have seen so much transmission related to the reopening of bars: people with impaired judgment, in a crowded indoor place, without masks, yelling to be heard- it’s a recipe for disaster.

people in masksDeciding who and who not to voluntarily interact with is likely the hardest part of the risk reduction decision-making process. You can’t change the decisions other people are making, but you can change the decisions you make in relation to those people. I have a number of friends who I have told that I will see them in 2 weeks (or one week and a negative test) after they have traveled to or had guests from an area that has medium or high COVID-19 activity. My son is traveling out of state for sporting events this summer and I am quarantining from him and he is quarantining from friends and work as per state guidelines.

Staying safe and COVID-19 free is a balancing act with many moving pieces and the best we can do is be informed about risks and try to minimize them. Risk reduction helped to reduce new HIV infections in the past, and COVID-19 risk reduction is a great tool to evaluate and reduce risks for becoming infected with COVID-19.

I hope that everyone is concerned about the spread of this deadly virus. I know not everyone will make the same decisions I do, and I know I am taking more risks than I would if I were 80 or obese (the second-highest risk factor for death from COVID-19 after age), or immune-compromised.

I encourage each of you to take a look at the activities you are currently engaging in, the risk involved, and, if high risk, asking if doing the activity is worth your life. COVID-19 risk reduction can hopefully help reduce your risk of catching COVID-19, but the only guarantee for staying uninfected is having zero interaction with people, which is impractical.

COVID-19 Risk Reduction: Livable Guidelines to Decrease Disease Transmission



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