May 18, 2020 Vol. 6: Restrictions Are Easing. Yikes, Now What? Perspectives on lower-risk behaviors that are more sustainable in the long term.

San Francisco, CA.  Hold on tightly folks. Shelter-in-place and other restrictions imposed by state and local governments to slow COVID-19 are being loosened, and even lifted in some parts of California and the United States, without any comprehensive federal plan or testing strategy. At the federal level, chaos, lies, and gaslighting are preferred over planning, testing and leadership. Last week, Mr. Trump opined that COVID testing increases the number of novel coronavirus infections. This truly outrageous statement is beyond magical thinking. It is akin to suggesting there’s no need to use birth control to avoid pregnancy—instead, just skip the pregnancy test.

In the United States, the process of reopening is occurring mostly on a county or state by state basis, with some variations at the city level. Once states and localities reopen, they will be under intense pressure not to shut down again even if a second wave hits later this year. I urge you to continue to pay attention, looking and listening for hot spots and adverse trends. Stay in touch with us at GetzWell Pediatrics for nuanced and updated science-based advice and information, including how to better maintain a strong immune system

While we have dramatically slowed the spread of COVID-19 in the Bay Area by sheltering-in-place, practicing social distancing, and some of us wearing masks, the virus is still very much among us. How should we approach reentering the world, especially after having sheltered in place successfully for the last two months? My strong recommendation is to continue to practice social distancing, wash your hands frequently, wear masks when in public, avoid commercial airline flights and gatherings of more than 10 persons (adults and kids combined), and continue to exercise good judgement. Keep in mind that when you wear a mask, you are not only protecting yourself but messaging to others that you care about their health.

Every day, we continue to learn more about this terrible virus and the range of symptoms it causes. With respect to our children and young adults, we are seeing symptoms which weren’t initially reported such as COVID toes and foot lesions. What also has emerged is a (thankfully!) rare multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 that has been described in kids in the United States and Europe. Affected children don’t present with respiratory symptoms but instead have persistent fever, a rash or changes in skin color, red eyes or conjunctivitis, abdominal pain, and swollen lymph nodes. If you notice any of these symptoms, you should contact us or your pediatrician immediately. 

As economies have massively stalled and people have expressed impatience with (or in some cases, militaristic opposition to) the sheltering-in-place and other safety measures governments have imposed, policies have begun to shift. In California, we’ve moved to “Stage 2,” of the “Resilience Roadmap” plan, which allows the gradual reopening of lower-risk workplaces

This reopening is happening even though over the past week, California has averaged 1,886 new diagnosed cases (undiagnosed is likely much higher) and 70.3 new deaths every day. Widespread diagnostic testing for COVID-19 in California had been woefully inadequate through early May and contact tracing has only just started. On a positive note, last week, Governor Newsom greenlighted COVID testing at pharmacies in California. A negative, on May 8th, officials in San Bernardino County, California, lifted their mandatory mask requirement and by May 16th, health officials reported that the number of new coronavirus infections for the week ending May 15th had doubled to 782 cases in the County compared to the prior week. 

The risk of a second wave of infection is very real and, as some countries are already proving, relaxing restrictions has meant an increase in infections. If we look at a state like Wisconsin, among a number of others, partisan politics appear to matter more than protecting public health and limiting severe illness and death. After a majority of the Wisconsin Supreme Court sided with Republican legislative leaders and struck down Democratic Gov. Tony Evers’ shelter-in-place order last week, images of unmasked people partying in local bars without any social distancing were widely circulating. Sadly, I predict COVID infection levels will be surging in Wisconsin in two to three weeks.   

From a purely public health perspective, it’s not at all clear that restrictions should be relaxed now. But it’s happening anyway. And certainly no one can deny we’re all fed up with being locked inside, particularly as the weather improves. As Julia Marcus, Professor of population medicine at Harvard Medical School, thoughtfully wrote in Quarantine Fatigue is Real, “…the choice between staying home indefinitely and returning to business as usual now is a false one. Risk is not binary. And an all-or-nothing approach to disease prevention can have unintended consequences.” We need a manual on how to have a (safe) life during a pandemic.

With the level of infection down right now in the Bay Area, I urge you to prepare for a potential second wave in September/October—just as the influenza season begins. Please plan on getting a flu vaccine (we typically receive flu vaccine shipments in late August/early September) as many scientists believe individuals can contract both Influenza and COVID at the same time. While the influenza vaccine isn’t perfect, and in a typical year about 50% of adults skip it, my view is that for the 2020-21 flu season it would be imprudent for families to take the risk when flu shots will be widely available.

Read on for some additional current thoughts on ways to adjust our behavior to keep ourselves safe in light of eased restrictions.

How should we approach venturing out?

Public Spaces

As restrictions ease, all of us will need to continue to exercise lots of personal responsibility. I urge you to be patient and not too eager to get back out into public spaces or dining inside restaurants. After all, just because you can go somewhere or do something doesn’t mean it’s a good idea or that you should. Cruise ships are planning to set sail again as early as August—you could go, but many people think that planning a cruise now is, in a word, reckless. 

Masks

We’ve not only seen a lot of disagreement and some violence over wearing masks, but also have witnessed how poorly the federal executive branch has been behaving around mask wearing. Everyone, including children four years or older, who are out in public or in commercial businesses or retail stores, should be wearing a face covering or mask—this is true even though no one may be enforcing it. The reality is we have compelling evidence showing that widespread mask wear works. Your mask protects me; my mask protects you. In fact, if 80% of Americans wore masks, new infections would plummet. All of us need to make good choices that promote health and these choices benefit not only ourselves and our families, but also our communities.

What constitutes higher risks of infection?

Successful Infection

An important fact to understand is that in order to be infected with COVID you need to get exposed to an infectious dose of the virus. Another way to think about this is “successful infection” depends not only on exposure to the virus, but also the time of exposure to the virus (Successful infection = Exposure to Virus x Time). Whatever we can do to limit our exposure to the virus (by keeping our distance from each other, covering our faces, washing our hands, staying in well-ventilated areas, and so forth) as well as limiting the time we are exposed to the virus will help prevent infections.

The “Exposure to Virus x Time” formula is also the basis of contact tracing. Anyone you spend greater than 10 minutes with in a face-to-face situation can potentially transmit the virus. Individuals who have the virus and who share a space with you (an office or a vehicle or in a restaurant, for example) for an extended period increase your risk of infection, even if they are asymptomatic.  

My thoughts on living during a pandemic have evolved and become more nuanced. I am starting to make decisions about venturing out within the context of a “harm-reduction” model, which acknowledges that most of us cannot reduce the risk of infection to zero via staying in for weeks or months on end. This model recognizes that some people are going to take risks, whether public-health experts want them to or not—and instead of condemnation, offers them strategies to reduce any potential harms. This approach meets people where they are and acknowledges that individual-level decisions happen in a broader context. See the article referenced above by Harvard Professor Julia Marcus for more details. 

Practically speaking, if we are feeling even a little bit sick, or our children are acting like they might be coming down with something, we need to stay home (and keep them home). When we do go out, we need to remember that there are plenty of instances of asymptomatic transmission of this virus. Again, we must cover our faces, maintain at least six feet of distance between us and anyone else, not touch our faces, and wash our hands diligently or use an effective hand sanitizer (here’s a DIY version).

Necessary Activities

What should “necessary activities” include as we weigh spending time out of our homes? (For example, should parents postpone well-child visits or vaccinations and what about seeing grandparents or attending birthday parties?)

A lot of these decisions are going to come down to personal choice and weighing risks. Eventually, we’ll need a haircut, for example, and not all of us are equipped to take matters into our own hands. 

When barbering and stylist services are available again, you should keep in mind the “Successful infection = Exposure to Virus x Time” formula and do everything you can to limit the chance of and time of exposure. Keep this in mind if you are faced with deciding whether to attend an event—anything from a birthday party to a wedding or a funeral. Such events often take place inside and involve prolonged exposure to others which significantly raises the risk of contracting the virus. 

As a general matter, before you go somewhere, call ahead and ask questions about how the business or event is operating. Can you get curbside pick-up? When are their busiest times? Do workers have the protective equipment they need? When you are at the business, pay attention to whether the answers you received match your experience. If they don’t, you may want to leave or reschedule and then follow up by phone to help keep everyone safe. 

This is a manual or guide with perspectives from three public health experts to help with measuring risk.

Well Child Appointments

Regarding healthcare, it’s vitally important, now more than ever, to maintain your family’s health, and that includes staying on track with well-baby and well-child visits and vaccinations. Do not postpone them. The American Academy of Pediatrics (AAP) reiterates that in this COVID era, “[c]onsistent with previous guidance, all well-child care should occur in person whenever possible and within the child’s medical home where continuity of care may be established and maintained.”

At GetzWell, our biggest concern is your family’s health. We are continuing to prioritize you and your children, your health and safety during this pandemic with our low patient volume, no waiting room time, and the requirement that everyone wear masks. We pre-screen all families and designate one exam room per office as the space where we will see children who are ill (but not with COVID symptoms). We are also combining telemedicine visits followed by shorter office visits (such as measuring height and weight, giving vaccines and checking for strep or ear infections). We are continuing to offer optional home visits and “drive-by” immunizations when appropriate and preferred. 

For any patients with clear COVID symptoms, we will work to support them via virtual/video visits and teleconference, or we’ll refer them to and collaborate with an appropriate urgent care or ER. We clean every room thoroughly between patients, have removed access to toys and books, wear protective gear during all appointments, and all of us will be COVID tested on a regular basis. If you have any questions about our hygiene and safety practices, please ask and we’ll be happy to discuss them with you.

But what about . . . 

I know. There are so many situations and factors to consider as we learn to move in the world again. We’ve gotten many questions about the return to daycare and attending summer camps. We are still in very wobbly territory due to the lack of coordination at the federal level, the failure to mobilize and enable widespread testing and unimplemented test-trace-isolate measures. As a result of these critical shortcomings and because of the virus’s ability to be spread by asymptomatic carriers, we are wrestling with making universal recommendations for our families. We encourage you to reach out with your questions and concerns. For now, we will endeavor to guide you based on your specific circumstance and the known facts. 

We found this publication from the Washington State Department of Health to be the most helpful child care resources and recommendations that we’ve reviewed thus far. We concur with these guidelines with respect to a return to childcare after suspected illness:

Staff members or children who have signs of suspected or confirmed COVID-19 can return the child to the care facility when:

  • At least 3 days (72 hours) have passed since recovery – defined as no fever without the use of  medications and improvement in respiratory signs like cough and shortness of breath; AND
  • At least 10 days have passed since signs first showed up.

At GetzWell we want to support you through one of the most challenging times in modern history. We will figure this out together.

Julia Getzelman, MD was educated at Stanford University and Yale University Medical School. She is the founder and CEO of GetzWell Personalized Pediatrics, which is a direct primary care medical practice in San Francisco, serving infants, children and teens as well as providing functional medicine and nutrition consultation and using genetic polymorphisms as a foundation for treating a variety of chronic health problems in children and adults including ADHD, anxiety, behavior issues, GI complaints and autoimmunity.