Midsommar Update: cautiously optimistic… if you wear a mask

Let’s talk about COVID-19 again. I want to share just a few paragraphs to simplify recent, good data that might lessen your anxiety over rising cases, the paradoxically increasing opportunities to spread this largely untreatable virus, and looming school start dates. And if you read no further the upshot is this: wear a mask and avoid places and situations where large numbers of people are enclosed in spaces without them.

For those of us in and around Boston, the numbers are promising. The effective reproduction rate of COVID-19 is now under 1; and when the RT is under 1, the virus stops spreading. From a microbiological perspective, this makes no sense. COVID-19 has not mutated dramatically and we are nowhere near herd immunity making hosts for coronavirus harder to find. It’s simply our behavior that has led to this decrease. Every canceled concert, empty seat at Fenway, closed bar, masked wait staff at outdoor restaurants, and postponed graduation party helped. YOU helped. Good job, Massachusetts!

With the RT below 1, our essential workers at grocery stores, pet groomers, and fast food joints are also safer. But as we relax stay-at-home orders, we need to personalize our own risk assessment: if you contracted COVID-19, how likely is it to kill you? When I first wrote about the novel coronavirus, citing data from Wuhan, 15% of patients required hospital care and the infection fatality risk (IFR) was over 5%. This number was terrifying as the scale of the disease was taking shape. Conservative estimates of 40% of the population ultimately contracting this virus could have resulted in 7 million Americans dying. This is why Dr. Fauci was on TV every night. Three months later, scientists have more data and that number has dropped dramatically. A promising study group from the Diamond Princess cruise ship tested all 3711 passengers and staff, effectively capturing even the asymptomatic carriers, and estimated an IFR closer to 1. As testing improved and widened, other studies (albeit quickly calculated and not-yet-peer-reviewed) found IFRs hovering between 0.5 and 1. And even if we’re still underestimating this, it’s a far cry from 5.

You can see here and here how well Massachusetts is doing IFR-wise. Another heartening statistic is a death rate of zero (ZERO!) for patients under 19. Unfortunately, these statistics don’t suggest we can stop worrying about Grandma. A closely studied population in Geneva stratified the IFR by age and found that in a city with sufficient hospital capacity and excellent medical care, the risk for those over 65 years of age is still between 4 and 7%. Other articles you have probably already read suggest that many of those patients are also overweight, diabetic, hypertensive, immune-compromised, etc. The best way to protect our elderly and at-risk loved ones is to prevent them from getting COVID-19 at all.


Odds are, you’re already doing this. Masks masks masks, limiting exposure, and close surveillance of your own health. Back in March when tests were sparse and we had only just stopped doing spin class, Sunday mass, choir rehearsals, and travel team sports, we had no idea who in our midst could be carrying and spreading COVID-19. Strict shut down was essential. Today, scientists are less worried about you contracting coronavirus from your play dates and take-out containers than from a “superspreader.” Pockets of new cases arise as people with no symptoms (or let’s face it, probably a little under the weather but ignoring it) and who aren’t wearing masks unwittingly attend activities that should still be verboten. An alarming example out of India is cautionary: after a wedding reception where over 350 guests were somehow allowed, nearly 100 townsfolk were infected. Though most of those who contracted the disease were asymptomatic and ultimately isolated, the 30-year-old groom who had exhibited all of the telltale COVID-19 symptoms died only two days after the ceremony. This devastating case illustrates the tragedy that ensues when a person with a high viral titer (the groom) is widely exposed (parties over 20 people) in an enclosed venue (reception hall) at exactly the wrong time (active infection with droplet-spewing symptoms).

The Indian wedding example is what is happening in areas that now need to reverse course and reinstate restrictions. As unmasked young people flocked to restaurants, bars, and parties, it took only one superspreader in their midst to undo three months of curve-flattening. Those who continue to hawk conspiracy theories and politicize mask usage will use new data to their advantage. Whoo-hooing revelers who contract the virus and don’t die (because they are young), will cause the IFRs to drop even lower. COVID-19 remains as deadly as it was in Wuhan in December, but will seem like it’s petering out.

It’s not.

So wasn’t this supposed to be an essay to alleviate your worries and bolster your confidence to send bored kids to camp and (please please please) back to school? Yes. Yes it is. The kids are alright, as the saying goes. And yesterday, Massachusetts posted its first day of zero (ZERO!) COVID-19 related fatalities. Unfortunately our at-risk population will need to remain vigilant until we have herd immunity (not happening any time soon) or a vaccine. I am loathe to give you my hunch about a vaccine, so let’s leave it at this: keep wearing masks and washing your hands, postpone parties, see friends outdoors… and maybe we’ll RT this thing to oblivion.


If Captain Kirk can wear a mask (while supporting the local bookstore… swoon…), let’s boldly join him in doing so.

The Re-Opening

What day is it? It’s definitely Friday, but Day Fifty Something for Lees on Lockdown. At this point most of us are well past the biblical 40 days of temptation and testing, but I think we’re collectively doing all right. From my screens, I see people reaching out to help those struggling mentally, financially, and spiritually. Our Steps to Success fundraiser could only be held via email blasts and status updating, but somehow raised more money for low-income students than we thought possible. Those who know how are sewing masks; those that don’t are buying them and delivering. Free meals, sidewalk chalk encouragements, Teddy Bear hunts, crooning from city balconies, family dinners, and Lisa on YouTube. This is the good stuff.

I’ve let loose only two primal screams of rage that were mostly directed at teenage boys WHO HAVE ONLY ONE JOB SO GET OUT OF BED ALREADY OMG WHY ARE YOU ASLEEP, but otherwise we’re safe and home and healthy, if also drinking far too much. One night after salivating over episodes of Salt Fat Acid Heat, I looked at our sleepy puppy and suggested to Bernie that we call it a night. It was 9:30. NINE-THIRTY. We hadn’t even finished the Pinot Gris.

Like all of you, I feel like I should be accomplishing stuff with all of this time. In addition to actual work that needs doing (65 manuscripts in the queue), maybe I should be learning to knit? Shredding old tax returns? Teaching Hero useless tricks? Shaping my eyebrows? Something. Instead, this cartoon pretty much sums up every day:


H/T to Tom Fraatz for posting this from @instachaaz

Zealot Sister lives in Georgia, so we’ve traded thoughts about the safety of doing the things their governor is letting them do. She has no plans for urgently overdue tattooing (wtf), but is going to brave the world and odds to attend to her grays and nails. Is that bonkers?

Probably not. Her county isn’t a hotbed of positive cases. But then again, they haven’t tested everyone, so who can say? With strict hygiene and mask compliance, could it be safe? Safe enough? Honestly, I don’t know. But we’re Americans and not typically great at rule-following when doing so feels like an affront to our personal liberty—or even just makes our glasses fog up. Really, we’re gonna be the worst at this re-opening thing.

Here’s what I do know: as the country starts allowing us to eat together and permanently ink each other–either in a stepwise sort of scientific way or as a recklessly impatient public experiment– my phone is going to blow up the same way it did when the WHO finally said “pandemic.” I’m happy to be your go-to non-practicing physician and immunologist, but at the beginning, I had more answers. Now, nothing seems certain. And as a scientist, when nothing seems certain, it is because we don’t have data.

The smartest people are offering models and recommendations that seem to change daily, but they are still guessing at how many of us have been exposed. The R naught, or coefficient of infectivity—essentially how contagious a virus is—was originally estimated between 2 and 3 for COVID-19. Newer data suggests it could be twice that. And if asymptomatic virus-shedders getting their gel tips and lowlights can infect 5-6 people, a second spike bigger than the first might be inevitable. An R naught over 5 also means we need to wait until over 85% of us have “beaten” coronavirus before we can spring the kids from Zoom School and back to square pizza Fridays in a brick and mortar way in the name of “herd immunity.”

Are we willing to risk the morbidity and mortality of thousands more to achieve this? Or should we suffer this no-end-in-sight life without dine-in restaurants, grandma hugs, or Sox games until a vaccine or miracle treatment is widely available? More importantly than when this ends is how.

Most of us are itching for sero-positive proof as a Get out of Jail Free Card to get back to a pre-COVID-19 existence, and a quick and widely available antibody test will give us a clearer picture of where we stand immunologically. But it won’t be the panacea we crave. Most if not all tests that have been authorized for use are only allowable through the Emergency Use Authorization (EUA) pathway. Doesn’t mean they are bad tests. They’re just tests that haven’t been… tested. And as a result there could be a significant number of false positives because coronaviruses are as common as, well, The Common Cold. There can also be a significant number of false negatives because your plasma cells pooped from combating COVID-19 have stopped making IgG because your memory B cells can always pump out antibody later, if needed.

Do you wanna know how these tests work? You can Google ELISA or trust me when I tell you that they slather a shmear of COVID-19 surface protein onto the bottom of a teeny plastic well and test if your blood is carrying antibodies that stick to it. Some identify IgM antibodies—the first ones your body uses to fight disease—suggesting a more recent response to an exposure. Others detect IgG antibodies—made by B cells that “learned” a bit more about the invader, and indicate a later or resolved infection. Some tests can detect both. But the antibody to the shmear doesn’t prove that they actually neutralize the COVID-19 you transferred from the grocery cart to your nose. The test doesn’t mean your antibodies are effective warriors, it just means they stick to the COVID-19 protein shmear.

What will an antibody test tell us and how can it shape our path forward? It will give scientists more data, but only as much as a stack of Polaroids from the table centerpieces will tell you about how great the wedding was. The IgG assay is only a snapshot. To wit, if we tested everybody right now, we’d likely find that far fewer than 85% of us have mounted an IgG immune response to COVID-19. Herd immunity is likely many months (and deaths) away. What is the power of your personal IgG positive test? Scientifically, not much other than proof that you were exposed. Also, your laminated IgG+ CoronaCardTM might not protect you from a newer, mutated version of the virus… and we have no idea if or when a COVID-20 will emerge.

SO WHAT CAN WE DO? I think the only way forward is to learn from countries that take personal hygiene (mask-wearing, hand-washing, forbidden handshaking and double kissing) seriously. We can dramatically reduce transmission if we maintain the 2-meter rule as much as possible, wear masks, and act like reasonable people in the midst of a pandemic. It won’t be forever… just until we have more data, a treatment, a vaccine, or herd immunity. As the country opens up, we’ll move about in different ways that protect others and ourselves, and I hope we’ll be patient and kind as everyone gets on board. Seven weeks ago I could meet you bare-faced at Starbucks, kiss you hello, catch a late movie, or watch the Celtics with thousands of fans. We’ll get there again. Just not tomorrow or because your governor said you can. Slowly, surely, with caution, common sense… and a mask.


Buying these from Remy supports #Masks4Meals, providing food for caregivers at Mass General… and they’re wicked cute.