Nagrik Dialogue

Amid the Coronavirus Crisis, a Regimen for Reëntry

Health-care workers have been on the job throughout the pandemic. What can they teach us about the safest way to lift a lockdown?

By-Atul Gawande

In places around the world, lockdowns are lifting to various degrees—often prematurely. Experts have identified a few indicators that must be met to begin opening nonessential businesses safely: rates of new cases should be low and falling for at least two weeks; hospitals should be able to treat all coronavirus patients in need; and there should be a capacity to test everyone with symptoms. But then what? What are the rules for reëntry? Is there any place that has figured out a way to open and have employees work safely, with one another and with their customers?

Well, yes: in health care. The Boston area has been a covid-19 hotspot. Yet the staff members of my hospital system here, Mass General Brigham, have been at work throughout the pandemic. We have seventy-five thousand employees—more people than in seventy-five per cent of U.S. counties. In April, two-thirds of us were working on site. Yet we’ve had few workplace transmissions. Not zero: we’ve been on a learning curve, to be sure, and we have no way to stop our health-care workers from getting infected in the community. But, in the face of enormous risks, American hospitals have learned how to avoid becoming sites of spread. When the time is right to lighten up on the lockdown and bring people back to work, there are wider lessons to be learned from places that never locked down in the first place.

These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus. We need to understand these elements properly—what their strengths and limitations are—if we’re going to make them work outside health care.

Start with hygiene. People have learned that cleaning your hands is essential to stopping the transfer of infectious droplets from surfaces to your nose, mouth, and eyes. But frequency makes a bigger difference than many realize. A study conducted at a military boot camp found that a top-down program of hand washing five times a day cut medical visits for respiratory infections by forty-five per cent. Research on the 2002 sars coronavirus outbreak found that washing hands more than ten times a day reduced people’s infection rate by even more. Disinfecting surfaces helps, too, and frequency probably matters, although I haven’t found good research on this. The key, it seems, is washing or sanitizing your hands every time you go into and out of a group environment, and every couple of hours while you’re in it, plus disinfecting high-touch surfaces at least daily.

That is not enough, however, because environmental transmission may account for as little as six per cent of covid-19 infectionssars-CoV-2, the virus that causes covid-19, spreads primarily through respiratory droplets emitted by infected people when they cough, sneeze, talk, or simply exhale; the droplets are then breathed in by others. (Loud talking has even been shown to generate measurably more droplets than quieter talking.) This is why physical distancing is so important. We have all now learned the six-foot rule for preventing transmission of contagion-containing droplets. In my hospital system, observers gently remind us to stand the prescribed distance apart on escalators and in the elevator line; we allow no more than four people on elevators that used to carry more than twenty (a nightmare at shift changes). We’ve turned as many internal meetings, patient visits, and team huddles as possible into video meetings, even if someone is right across the hall. When we can’t avoid face-to-face encounters, we’ve put up Plexiglas barriers and spaced our chairs and work stations farther apart.

The six-foot rule isn’t some kind of infectious-disease law, however. There’s no stop sign at six feet that respiratory droplets obey. Public-health guidelines, in fact, originally set the at-risk distance at three feet or less, based on theoretical models going back to the nineteen-thirties, simulation studies, and experience in previous outbreaks, such as a 1981 outbreak of infectious meningitis in a Texas elementary-school classroom. That outbreak began in a cluster of five girls seated together on one side of the room. One infected the other four. Investigators later took measurements: the distance from one girl’s seat to another was about two and a half feet. Close contact at lunchtime spread the Meningococcus bacteria to other children, who transmitted the disease in their classrooms. In all, thirty-one children became ill or were carriers, and the spread was mainly in two classrooms where the chair-to-chair distance was three feet or less.

Even then, it was already apparent that respiratory illnesses frequently travel farther. Past guidelines from the C.D.C. also cited a 1948 military study in which almost fifty young men with confirmed Streptococcus infection—strep throat—were asked to cough, sneeze (with the help of a sneezing powder), and talk. Petri dishes and air samplers were placed at various distances to capture bacteria. All three activities dispersed contagion. Sneezing was the worst.

A study conducted at a naval base in the nineteen-forties found that germs were most commonly collected within a foot and a half of the sneezing subject, but in some cases they could travel much farther.

In the most common pattern, bacteria grew only on petri dishes placed on the floor a foot and a half from the sneezer. In ten per cent of cases, bacteria were captured only by the air samplers. In twenty per cent, no streptococci were recovered anywhere. But one recruit spewed large quantities of bacteria into petri dishes and air samplers almost ten feet away. “This subject,” the report noted, “was really an unusually good atomizer.” They’d caught him at a time of particular infectivity. A few days later, he wasn’t nearly as infectious anymore.

It has now become well recognized that, under the right conditions of temperature, humidity, and air circulation, forceful coughing or sneezing can propel a cloudburst of respiratory droplets more than twenty feet. Yet it wasn’t until the sars epidemic in 2002, after several cases documenting more distant spread, that authorities doubled the at-risk distance from three to six feet. In one case, a man with sars on a three-hour flight from Hong Kong to Beijing infected twenty-two people, five of whom died. The twenty-three passengers in the same row or the three rows in front of the index patient bore the highest risk: eight fell ill. So did the flight attendant for the patient’s section. Extending the recommended distance made sense. But six feet was simply a choice guided by practicality. People seven rows away—around eighteen feet—developed sars, too.

We’ve seen similar events in the current pandemic. Take, for instance, the now infamous Skagit Valley Chorale practice, on March 10th, at a church in Washington State. It was pre-lockdown, but there’d been enough coronavirus news to lead the group to suspend the usual hugs and handshakes and to sit farther apart than usual. According to choir members who were present, no one seemed ill at the start of the rehearsal. No one coughed. The singing was as powerful as ever. And that may have been the problem. There was an index patient who had been experiencing cold-like symptoms for three days, which worsened after the rehearsal and led to a diagnosis of covid-19. According to an investigation by the Skagit County Public Health department, fifty-two of the sixty other choir members in attendance subsequently fell ill. Thirty-two choir members tested positive for covid-19. Two died.

covid-19 isn’t actually crazy infectious. Measles is crazy infectious: for instance, in a 2008 outbreak in San Diego that began in a school where thirty per cent of students were unvaccinated, each infected child spread the virus to, on average, eighteen others—meaning that the disease has a “reproductive ratio,” or R0, of eighteen. By comparison, a person with covid-19 will infect, on average, only two to three others out of all the people he or she encounters while going about ordinary life. Exposure time matters: we don’t know exactly how long is too long, but less than fifteen minutes spent in the company of an infected person makes spread unlikely. (For instance, among four hundred and forty-five people who were within six feet of a covid-19 case for ten minutes or more, only two tested positive, both of whom had confirmed cases in their households.) But an R0 of two or three is more than enough to cause a pandemic. Given an average incubation period of five days, a single unchecked case can lead, over two months, to more than twenty thousand infections and a hundred deaths. The six-foot rule goes a long way toward shutting down this risk. But there are clearly circumstances where that is not sufficient. At the right point in the illness, under the right environmental and social conditions, one person can produce a disaster. In ninety minutes of choir practice, in a crowded church on a March day, with a woman at the height of infectivity, the R0 was in the dozens.

Hence the practices begun in Asia, and adopted by my health system, to institute daily screening of all employees, patients, and visitors for symptoms of covid-19. Anytime I want to enter a hospital building, I have to go to a Web site that I’ve bookmarked on my phone, log in with my employee identification, and confirm that I have not developed a single sign of the disease—a new fever, cough, sore throat, shortness of breath, loss of taste or smell, or even just nasal congestion or a runny nose. (Administrators could also have added a formal temperature check with an infrared touchless thermometer, but, although ninety per cent of symptomatic covid-19 patients eventually develop fevers, early on, fever is present less than half the time. So it’s the mild symptoms that are most important to screen for.) A green pass on my phone indicates no symptoms and grants me access to the hospital. Otherwise, I can’t work. In that case, the Web site directs me to call our occupational-health clinic and arrange for possible testing.

Testing when people have symptoms is important; with a positive result, a case can be quickly identified, and close contacts at work and at home can be notified. And, with a negative result, people can quickly get back to work and keep the hospital going. (Owing to false-negative test results, you are still required to wait until your fever has been resolved, and your symptoms have improved, for seventy-two hours.) Tests for people with symptoms are becoming increasingly available; this is no longer a problem for our hospital. Without these tests, people with symptoms have to self-quarantine for much longer—for at least seven days from the start of their symptoms and until they’ve been fever-free and with improving symptoms for seventy-two hours.

This self-screening is obviously far from foolproof. Anyone could lie. Nonetheless, in the first week of rollout, more than five hundred colleagues indicated through the Web site that they had symptoms. Through the first week of May, symptoms, often mild, prompted more than eleven thousand staff members to stay home and receive testing. Fourteen hundred of them tested positive for sars-CoV-2 and avoided infecting patients and colleagues. Daily check-ins are equally important for less measurable reasons: they send the right message. Embarrassingly, people in health care have often seen calling in sick as a sign of weakness. Screening has changed that. Toughing it out is now a shameful act of disloyalty.

Even the most scrupulous check-ins, however, can do only so much in this pandemic, because the sars-CoV-2 virus can make people infectious before they develop symptoms of illness. Studies now consistently indicate that infectivity starts before symptoms do, that it peaks right around the day that they start, and that it declines substantially by five days or so. This is the pattern we see in influenza. But it’s the opposite of the pattern we saw with the coronavirus that caused China’s sars outbreak eighteen years ago. That virus had a low risk of transmission until after five days from the onset of symptoms, which made it easier to identify and isolate cases before others got infected. No large-scale lockdown was necessary. It seems that there are also plenty of people who are infected by the virus that causes covid-19 who never become symptomatic, especially children. So far, studies of transmission networks have not revealed such silent carriers to be a major source of spread. Nonetheless, patients who do not yet show symptoms, or have just begun to, are turning out to be important vectors of disease.

That’s why we combined distancing with masks. They provide “source control”—blocking the spread of respiratory droplets from a person with active, but perhaps unrecognized, infection. Since March 25th, my hospital system has required all employees to wear disposable surgical masks. In early April, we began providing masks to all patients on-site. Patients pose a more controlled risk: they don’t come and go every day. As cases have become widespread in the community, however, staff have been at increased risk of picking up the virus at home and then spreading it to patients and colleagues.

So how effective are surgical masks? A study published in Nature last month shows that, if worn properly and with the right fit, surgical masks are effective at blocking ninety-nine per cent of the respiratory droplets expelled by people with coronaviruses or influenza viruses. The material of a double-layered cotton mask—the kind many people have been making at home—can block droplet emissions as well. And the sars-CoV-2 virus does not last long on cloth; viral counts drop ninety-nine per cent in three hours. Cloth masks aren’t as breathable as surgical masks, though, and that’s important.

Surgical masks are made of a melt-blown polypropylene fibre fabric, which, under magnification, looks like cotton candy. Most of the filtration this material provides isn’t from direct blockage but from an electrostatic charge applied to the fibre using a machine called, aptly enough, a corona charger. The static electricity captures viral particles the same way that a blanket in the dryer catches socks. This allows the material to breathe more freely. Cloth masks feel warm and smothering by comparison, and people tend to loosen them, wear them below their noses, or take them off more frequently. The fit of improvised masks is also more variable and typically much worse. A comparison study found that surgical masks did three times better than homemade masks at blocking outward transmission of respiratory viruses.

Don’t ditch your T-shirt mask, though. A recent, extensive review of the research from an international consortium of scientists suggests that if at least sixty per cent of the population wore masks that were just sixty-per-cent effective in blocking viral transmission—which a well-fitting, two-layer cotton mask is—the epidemic could be stopped. The more effective the mask, the bigger the impact.


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Nagrik Dialogue is the face of Nagrik Foundation’s communication skills that comes in the form of a monthly magazine. It will work as a bridge for those working at the grass roots level and those who support them in any form and manner.