April 13, 2022 – People need to make personal decisions about their risk for COVID-19 based on their comfort level, what they do in public, and the amount of virus circulating in their community, Anthony Fauci, MD, said recently.
But this vague recommendation may leave people wondering exactly what they should and shouldn't do now to balance safety with a strong desire to return to a pre-pandemic life that is as normal as possible.
At the beginning of the pandemic, when little was known about COVID-19, "everybody had to be extremely cautious," says Aaron Glatt, MD, chief of infectious diseases at Mount Sinai South Nassau in Hewlett, NY. "Now risk can be individualized."
There’s an exception for residents of Philadelphia, which will become the first big U.S. city to reinstate indoor mask requirements starting Monday.
Deciding whether to wear masks everywhere else, no surprise, depends on some personal factors: Are you over 50? Do you have a medical condition that places you at greater risk? Do you live with a high-risk person? Likewise, risk can vary based on how you interact with others: Do you avoid indoor concerts? Request outdoor seating at restaurants? Grocery shop at 11 p.m.?
The eased restrictions, relaxed recommendations, and an increase in case numbers in some states can add to the confusion.
Although people have heard about pandemic risk factors for more than 2 years, "it's tough because people are not good at assessing their own risk. Everyone thinks they're invulnerable, especially younger people," says Thomas Giordano, MD, a professor and section chief of infectious diseases at Baylor College of Medicine in Houston.
On a positive note, "we're at a phase of the epidemic where people can decide what's appropriate for them," he says. "Much of the country is doing very well."
Some Risk Factors to Consider
The experts consulted for this story shared some examples. If you are older and have multiple medical conditions, you probably should not be doing anything outside your home unless you are vaccinated, boosted, and wearing a mask, says Luis Ostrosky, MD, chief of infectious diseases with UTHealth Houston and Memorial Hermann-TMC in Texas.
"But if you're in your 20s, you have no comorbidities, and you're vaccinated and boosted, you probably can be doing more stuff outside and possibly in more high-risk settings," he says.
A history of COVID-19 combined with vaccination likely offers the highest level of protection, Glatt says. "A 25-year-old, triply vaccinated person who recently had COVID is a different animal than a 75-year-old unvaccinated [person who] never had COVID who is morbidly obese."
Also, if someone works where they come into contact with tens, dozens, or hundreds of people a day in close quarters, "the risk of exposure is substantial." Giordano says. On the other hand, "If you're retired and leave home mostly to take walks outdoors several times a day, your risk is probably low."
Join the Booster Club
Any time beyond 4 months since an initial booster shot would be an ideal time to get another vaccination, says Ali Mokdad, PhD, chief strategy officer for population health at the Institute for Health Metrics and Evaluation at the University of Washington School of Medicine in Seattle.
"The data shows that waning starts at 3 months and gets really low at 5 to 6 months," he says.
"The number one question I get right now is: Should I get my second booster?" Ostrosky says. "Again, what I've been advising my patients is, if you're older than 50, if you have comorbidities, if you're more outgoing right now, doing more stuff out there in the community, probably now is the right time to get your second booster."
"If you're younger, if you don't have comorbidities, and you're not going out that much, then you can probably wait a little bit longer, he says.
Peter Pitts, a former associate commissioner with the FDA, says that "more antibodies are better than fewer, and as many Americans as possible should get both a first and second booster."
"'Individualized risk' is a fancy way of saying 'personal responsibility,' says Pitts, who also is co-founder of the Center for Medicine in the Public Interest. "We need to pivot from explaining the data to putting it into the perspective of individual actions based on personal, familial, and community responsibility."
Pandemic Fatigue Could Play a Role
Asking people to keep up their guard after more than 2 years of the pandemic adds to the challenge. "People are tired. Definitely, everyone's tired. I'm tired of it," Giordano says
Ostrosky agrees. "What I've been seeing in patients, friends, and family is everybody is done with [COVID] and they're willing to take more risk than they used to before."
"Nobody wants to deal with this. Even infectious disease doctors don't want to deal with this anymore," Glatt says.
Giordano says it comes down to two questions: What is your risk of exposure to COVID, and what is your risk of bad disease if you are exposed?
A resource people can use to gauge their personal risk is the CDC County Check. The agency provides color-coded levels of COVID in a community searchable by US county: green for low, yellow for medium, and red for high
Most of the U.S. remains green at the moment, Giordano says, but if the level of concern goes from green to yellow or yellow to red, then universal recommendations – like those about to take place in Philadelphia – become more likely.
But national COVID-19 numbers miss about 93 out of 100 positive cases, Mokdad said in an interview with the Poynter Institute. A lack of reporting of positive home tests is part of the story, "but the majority of infections, about 80% are asymptomatic," he said.
"So folks do not go and test," Mokdad said, "as they do not have symptoms and hence a reason to do so unless needed for travel or they know they were exposed."
Giordano agreed the actual case numbers are likely higher, in part due to home testing. "I think there's more COVID out there now than there was a month ago or 2 months ago, but a lot of it is not being reported to health officials because it's being diagnosed at home."
Living in the Matrix?
Laying out a person's risk on paper might help people see what they're comfortable doing now and in the future if the COVID landscape changes once again.
Ostrosky says he's been advising people to create a "risk matrix" based on age, medical conditions, and what the CDC County Check indicates for where you live or plan to travel. Also consider how important an activity is to you, he says.
"With this three-axis matrix, you can make a decision whether an activity is worthwhile for you or not and whether it is risky for you or not," he says. "With this matrix and masking and vaccination, you can navigate the pandemic."
Enjoy Now, but Also Prepare
More new COVID-19 cases are not surprising "when there is a pullback on mitigation measures," Fauci said during the Sunday talk show.
"We're at that point where in many respects … we're going to have to live with some degree of virus in the community," he said.
Fauci does not expect a rise in hospitalizations and deaths to go with the new increase in cases. "Hopefully, we're not going to see increased severity."
Pitts was even more optimistic. "Dr. Fauci buried the lede: We’re winning. COVID-19 is moving from a deadly pandemic to a manageable, non-lethal endemic."
As with the flu, different prevention measures are recommended for different groups of people, Pitts says.
"I feel that we're going to be going into a cyclical nature on this, where we're going to be seeing highs and lows of COVID rates in different communities," Ostrosky says. "During the lows, do a lot of planning and prepare for a situation where you may be in a high-transmission setting again."
"We all need to take a huge deep breath and say, ‘It's not over but we're getting back to normal,’" Glatt says.