Is there a way to decrease contamination from packaging? 

If you want to play it extra safe, what you can do is open the packaging so you don’t have to touch it again to eat the food. Then, wash your hands, and then eat it. The reason is if putting the food into the package or delivering it contaminated the package, that will protect you. 

Jean McChristian emailed to ask: If people in two different households are self-quarantined for two weeks with no symptoms, can they get together inside one of their houses? Related, can she safely care for her toddler grandchild while her daughter and son-in-law work from home? 

If they’ve already been quarantined for two weeks with no symptoms, the chances of either being sick should be extremely low. Now, we’re assuming here that nobody’s cheating, if you will, being “mostly quarantined.” If she’s asking whether people who are still in the process of self-quarantine can get together, that’s a murkier area, because then you’re kind of stepping outside of quarantine. That’s especially true when folks are getting together with more people, getting together with family. But assuming that’s not what we’re talking about: Why not wait for a nice day and do it outside?

Megan wrote in to ask a similar question. She has a 3-week-old baby—congratulations, Megan!—and she wonders if it’s safe to get together with other family members, like grandparents, who have been staying at home but have gone out for things like grocery shopping. That’s going to be one of those edgy questions again, isn’t it?       

It is. It comes to a question of how you feel about risk. When I’m talking about it with my patients, I compare it to how different people order steak in a restaurant. One person says, “I want to know every last germ on this is dead. I want it cooked well-done.” Another one says, “I want it rare,” and says the pleasure of eating a rare steak is worth taking a chance. Who’s right? Well, you could argue that they both are, they just have different attitudes toward risk.

Realistically, if we’re talking about people who took protecting themselves seriously and have been quarantining themselves for a few weeks, you’re not taking a very big risk. For other situations where you are going out to the grocery store, probably taking a somewhat higher risk. In the meantime, what about Skype, Zoom,  FaceTime? I know it’s not the same, but it’s better than nothing.

While it seems like most people are following the guidelines about staying home and avoiding unnecessary contact, we do have to go out occasionally. Listener Dara Christoff wants to know what precautions are really necessary after a trip to the grocery store, for example. Should we just wash our hands when we get home or do we need to take off all our clothes and immediately put them in the washer and dryer and we take a shower?

I should probably mention here I am the family germophobe, and when I discovered a few weeks ago that Staples had gotten a shipment of Clorox wipes, I felt like a kid on Christmas when I clicked “order.”  But to answer your questions: How contagious is it? It’s not very hard to get. Again there’s that quirk that most young people don’t get badly ill. Coupled with that, it’s hay fever season, so if you’re young and invincible like we all once were, you might feel a little iffy—you might talk yourself into thinking you’re just having a bad allergy day. And now other people could be exposed.

Handwashing is a very good idea—even more so now—but just being around someone’s sneeze or cough is more than enough to get the coronavirus. Beyond that, there isn’t really enough evidence for me to say yes or no to a specific thing. My personal rule is that if I stayed in the car, paid by phone, and people put things in the trunk, I just wash my hands well. If I were actually in a store … to be honest, I haven’t been inside a store for quite a while now, probably coming up on a month. I’d probably shower. But better yet, use a grocery pickup or delivery service and skip going into the store entirely. I know … I miss it too.

We know that increased testing capability will be vital to track and contain COVID-19. Listener Brent England notes that it’s been hard for ordinary people to get tested, especially in the early days of the outbreak. Is that changing? And if so, what’s the best way for someone to get tested? Does it vary by city or state?

It’s changing, but not nearly as quickly as it needs to—both for health and for the economy. The reason behind that, to look under the hood for a moment, is that the World Health Organization categorizes countries as one of three things: isolated cases only, clusters of cases, or community transmission. Community transmission means we don’t even know who brought it where. We’re trying to get back to the “clusters of cases” category, such that public health authorities can try to fight individual fires. Specifics of testing vary by area—around here, there are drive-thru centers. That’s far better than going into a health facility, where if you haven’t actually been exposed yet, you could well be exposed by going there.

Listener Rich Thorne also wrote in with a question related to tracking the disease. The daily figures we hear reported focus on those who are sick and those who have died. But there’s a big difference between those two. So why aren’t the numbers of those listed as “recovered” higher than they are? Surely there are plenty of people who have recovered and are past the point of being carriers.

Some of this relates to the testing situation: To be defined as “recovered,” you need at least one positive test followed by at least one negative test. So if tests are scarce in your community and you’re feeling better, in the short term you’re not going to be listed as recovered. That’s actually for the best, statistically, because people who have had it may shed the virus in their stool for up to four weeks. 

Anna Marion wants to know if the death toll figures are falsely inflated by including those who maybe had COVID-19 but didn’t necessarily die from it. 

I think it’s far more likely that we’re understating the death toll than overstating it, because of the testing situation. Many places are saying, “Well, we don’t have a test, therefore we can’t say it was the coronavirus.” But when the death rate in a given area or a given facility goes up so sharply, that’s a pretty safe assumption even if individual death certificates don’t say “coronavirus.”

Justin Sylvestre wants to know if there’s any information about the number of people who have died who were smokers, or who used vaping devices before getting sick. Is that a big factor in how well patients are able to fight off the disease?

Let me say right at the outset that I think everyone who smokes or vapes should quit. Right away. If you’re having a cigarette right now, please find the nearest ashtray. You’re back? Great, and here’s some good news: Surprisingly, patients who have asthma and COPD may not be as hard-hit as was predicted, according to a recent comment in The Lancet. One theory is that many of them are on steroid inhalers, and since we now think that some patients do poorly because of an exaggerated immune reaction in the lungs, perhaps the steroids calm things down.

Linda Berg wrote to say her husband got sick in early February with flu-like symptoms. But his influenza test came back negative. What are the chances he actually had COVID-19? And related to that, if he had it before, can it come back?

Early February, when cases were still very rare in most of America, I’d say the chances of coronavirus depend very significantly on the area. If this took place in an area that had cases at that time, or if he’d visited a place that had cases at that time, then it’s a possibility. If there weren’t any cases known around there, probably not. An antibody test would answer the question.

If you’ve had it, can it come back? That’s kind of the $64,000 question here. With most viruses, the answer is no. We’re hearing of people who had a positive test, then a negative one, and then a positive one—and some with symptoms that went away and came back, suggesting that it’s not just a testing issue. It does sound like if a person gets it at all a second time, it sounds like it may be a lot less serious—which stands to reason, since the immune system now has an idea what it’s fighting.

That leads to another question from listener Marcia Johnson: “What do you think the actual likelihood is that researchers will be able to develop a vaccine for COVID-19?”

I think the chances are very good that there will eventually be a vaccine, but I do want to emphasize the “eventually.” The biotech world likes to toot its own horn a little and issue press releases stating that they’ve basically already won the fight, while saying between the lines that they’re about to start their first human trial. The key will be finding a vaccine that really works in those trials.

One reader asked whether new antibody studies from California and New York, showing more people may have been exposed to the coronavirus, means the mortality rate for the coronavirus is much closer to that of the flu.

The flu does not normally have a mortality rate of 0.37 percent, as an antibody study from Germany—that shows an area already in the process of reaching herd immunity—found for its region. Per U.S. Centers for Disease Control and Prevention figures, the 2019-20 flu season has seen 39-56 million cases of flu in America, with 24,000 to 62,000 deaths. Even using the highest death figure and the lowest infection figure, which would give the highest percentage, we’d get a mortality rate of 0.15 percent—making coronavirus about two-and-a-half times more deadly. This figure understates the danger for several reasons: First, we can fight flu with a vaccine and with multiple different drugs shown to be effective against it, and second, the coronavirus has proven to be devastating in the context of places like nursing homes. Moreover, the flu does not normally overload hospitals and ICUs to the extent we've seen with coronavirus, and that overloading is what brings the mortality rate up sharply.

So, to sum up: it’s true that the situation is not as dire as originally reported, but coronavirus remains a bad bug that deserves the caution it’s receiving.

From the beginning of the stay-at-home orders we’ve been told the goal is to flatten the curve. Listener Mark Wikner wants to know: Does that mean we’re reducing the number of cases or just spreading them out over a longer period of time?

Looking at countries that saw the coronavirus before we did, I think that if we can get proper measures in place, we’re actually reducing the total number. I’ve heard the claim that we’re delaying the inevitable, but I don’t really buy that. 

First off, remember that R-zero number, the number of people who catch the coronavirus from each person who has it. At baseline, just normal life, that number is 2.7—so each person who has it can expect, on average, to infect a little under three other people. 

But the good news is that we can change R-zero by changing our behavior. In an extreme case, if truly everyone stayed home for a month and nobody went anywhere at all, the R-zero would be exactly zero and the coronavirus would be eliminated from the world. That’s not feasible, but we are bringing R-zero down dramatically. Each intervention helps. Masks help. Handwashing helps. Social distancing helps. Doing each of those things together helps more. Everyone doing those things together, as a community, helps a lot more.

Beyond all of this, the stay-home orders buy time. We’re not realistically going to have a vaccine before we have to go back out, and we’re not going to have great data on whether any of the proposed treatments really help, but what we can have is better testing and better PPE—personal protective equipment. Both of those would help the cause a lot, and that situation can improve pretty quickly.

Some epidemiologists are disputing the value of flattening the curve, noting that we’re not really stopping the disease, we’re just slowing it down. They advocate for promoting herd immunity as the best way to stop COVID-19. That’s the approach Sweden has taken. Several listeners wrote in to ask about this, including Carolyn and Cristian. So in your view, what role does herd immunity have to play here?

Sweden’s actions have been reported that way in America, but the truth is a little different. Their foreign minister described the strategy as “No lockdown, and we rely very much on people taking responsibility themselves.” Keep in mind this is Scandinavia: It’s a pretty socially distant place to start with, and a place where a government can make suggestions that people will, on their own, treat as orders. You can see that as a good or a bad thing, of course, but it does mean that we as Americans tend to hear “no lockdown” and think they’ve done something dramatically different. They’ve already cut the maximum gathering size to 50 people, and I wouldn’t be surprised if they take further steps in weeks to come.

That raises questions about what life will be like here as we gradually start to reopen stores and businesses. Listener Tom DeZarn in Michigan wants to know: “As we come out of the coronavirus isolation and quarantine phase and get back to real life, I’d like to know from the good doctor if it is still necessary to keep a 6-foot distance of safety between you and someone you’re talking with, if you both are wearing facial coverings.”

Social distancing is even more important now than it had been, because I think it’s likely that cases will start to tick upwards again. If you’re both really wearing proper face coverings, 3M N95s, that might be a little different. But those are still very scarce. I love the heart behind homemade masks, and I’d wear one if I didn’t have a 3M. But the effectiveness, unless you’re just using them as a pre-filter or a way to keep dirt off your N95, is pretty questionable.

Becky Rubio is a retired nurse also thinking about masks. She wonders why so many people are wearing them in public, especially when healthcare workers are still facing equipment shortages.

Asymptomatic spread is the underlying reason—we can’t just steer clear of visibly sick people and figure that we’re good. As for folks wearing masks in public, they might be healthcare workers in civilian clothes, wearing their own personal masks. They also might have poor immunity from chemo, have other health problems that increase their risk, or have a sick loved one who depends on them not to bring the coronavirus home. They also might have a mask that they’d already been using, prior to the coronavirus becoming a problem. Remember that these masks used to be sold at Home Depot for a buck or two, and plenty of folks had used ones lying around their homes from the last time they had to sand something. You can’t really donate your old used ones to the hospital, so why not wear them?

You mentioned the likelihood of a resurgence in cases. Susanna Dundore is wondering about that, too, specifically as it relates to college students headed back to campus in the fall. Are we likely to see them coming home again if we get a resurgence of cases?

I wish I had a crystal ball! I do think one lasting societal change from the coronavirus will be an increase in ideas like distance learning. If I were an incoming college freshman, I’d be curious, simply because I’d rather live at home with my family than in a cramped, expensive dorm room far from home.

So if we’re reasonably sure we’ll see secondary rounds of infection, listener Natalie Weber wants to know: How can we determine the end of the threat?

Since a vaccine isn’t going to happen in that time frame, the goal is to get back to a situation where every case can be tracked, with quarantining anyone who’d been in contact with that case. If the cases become rare enough, that’s possible. Think of a fire department that’s put out a major fire, now just standing by and putting out little flare-ups. That’s the general idea. It’s not truly the end of the threat, but it’s a new phase in fighting it.