As we prepare to head into our second fall with the coronavirus, it’s admittedly a strange time. On the one hand, the situation is better than last year, primarily because we have vaccines that are doing a terrific job of protecting the roughly 60% of Americans who are eligible and fully vaccinated, and to some extent, the additional 10% who have gotten their first dose. But things are also worse, mainly because the very contagious and possibly more dangerous Delta variant currently makes up about 99% of the coronavirus in circulation in the United States. The Delta variant has caused an uptick in infections, hospitalizations and, sadly, deaths, especially in parts of the country where vaccination rates are lagging. To add to this worrying trend, serious disease requiring hospitalization is affecting younger and healthier age groups, including children. What’s becoming clear is that we, locally and globally, are not going to be able to stamp out the coronavirus completely. Experts predict it’s going to become endemic, possibly joining the other four or so common cold coronaviruses in circulation. “We’re not going to eradicate this coronavirus like we’ve done with smallpox; it is something that I think is going to settle into a more seasonal pattern, like the flu and colds …” said Linsey Marr, professor of civil and environmental engineering at Virginia Tech and an expert in the transmission of infectious diseases via aerosols. “But right now, because it’s novel and so many people are not immune to it, it’s really ripping through the population. But I think five years from now, we will have much greater immunity either through vaccination or natural infection,” she said. That means we are going to have to learn to “dance” with the virus – a safe co-existence – without constantly stepping on each other’s toes. Dancing with Covid-19 Like with other diseases, this requires tight control – giving the virus as little freedom as possible so as not to set the stage for the surge of sickness and death we experienced last winter. It also means finding a balance between the extremes – on the one hand, lockdowns that trigger economic and personal chaos, and on the other, putting the rights of individuals above the good of society as a whole – and moving toward the middle. That way we can more safely enjoy all of life’s pleasures – family gatherings, live sports and arts events, travel, indoor dining – with only minor inconveniences, like vaccines and masks, during times of substantial viral spread. “Let’s be creative with making adjustments to life, rather than saying it’s all or none, because that was kind of the feeling last year,” said Dr. Jeremy Faust, an emergency physician at Brigham and Women’s Hospital and an instructor at Harvard Medical School. So, what can and should we be doing now and into the fall to make sure we follow the path to living well with the virus? Over the past couple weeks, we spoke to experts in the world of pandemic preparedness, infectious diseases and virology to try and get guidance on how to best and most safely live our lives going into the fall. Many of these experts live with the same concerns as everyone else, including managing the safety of unvaccinated children, and balancing the risk, given the Delta variant, with a deep desire to live a more normal life. While nearly everyone is reluctant to make predictions nowadays, there was agreement on five strategies to be put in place. I have included our conversations, their specific reasoning, and the evidence to bolster the claims. First thing first: Vaccinations At the top of the list for all our experts: vaccinations. “We need to get as many people vaccinated as possible,” said Marr. “I know that kids under 12 can’t get vaccinated, but when everyone else around them is vaccinated, it helps protect them too. But that’s the first thing.” Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota and an epidemiologist, echoed the sentiment. “The first thing is, we need to continue our programs of vaccination,” he said, adding that the current surge we are experiencing won’t be impacted by those efforts since it takes four to six weeks to develop full immunity. “But having said that, it is absolutely critical to get people vaccinated now, because … it’s very likely that we will see additional surges, whether this fall or this winter. And the way to minimize those is, in fact, get people vaccinated. So please do that.” The government is also getting tougher in its efforts to get more people vaccinated. President Joe Biden announced on Wednesday that nursing homes will have to require their staff to be vaccinated or risk losing Medicare and Medicaid funding. Also Wednesday, government health officials from multiple agencies announced that booster shots will be offered starting the week of September 20 to Americans who are eight months or more beyond their second dose, due to concerns about waning immunity. That move comes on the heels of the US Food and Drug Administration last week authorizing a third vaccine dose for immunocompromised Americans. Keep masks around, like an umbrella Among our experts, masking up was seen almost as important as getting everyone vaccinated – especially with the ubiquity of the Delta variant. Unlike earlier variants of the coronavirus, Delta has been shown to exist in the nose and upper throat of infected people, vaccinated and not, in almost equal amounts, even though the viral load drops off much more quickly in the vaccinated, according to an as-of-yet unpublished study out of Singapore. (The vaccinated, however, get infected less frequently, develop severe symptoms much less frequently and almost always avoid hospitalization and death.) “We need universal masking again. Because that … reduces the amount of virus that’s in the air around us [and] helps protect you individually from breathing virus in the air around you,” said Marr. “People can be spreading virus without any symptoms. So, we need this really until we can get the number of cases down.” Right now, most of the country is being “showered” with virus, and masks, like an umbrella, can help protect us from getting drenched. When viral transmission is lower, it will be a lot safer to set aside our masks. Marr added we may not need to mask all the time. “We might want to use them in certain areas at certain times of year when there are outbreaks of colds and flus caused by respiratory viruses,” she added. Osterholm called the controversy surrounding masking “terribly unfortunate.” “Because the vaccines won’t have an immediate effect for those that are not vaccinated yet, we have to continue to emphasize protection …” he said. This lines up with the recently updated mask guidance from the US Centers for Disease Control and Prevention that recommends everyone, regardless of vaccination status, mask indoors in areas with “substantial” and “high” levels of Covid-19, which, currently applies to about 99% of the country’s population. Osterholm and Marr recommended good quality masks, such as an N95, KN95, KF94, or a cloth mask that has a dedicated filter layer in the middle. Osterholm added these masks should be in plentiful supply now, compared to early in the pandemic. Masks + ventilation = Safer schools Worrying public health experts is the fact that this fourth surge of coronavirus infections is coinciding with the reopening of schools and colleges throughout the country, causing parents, teachers, politicians and municipalities to clash in some states over basic public health measures, specifically vaccine and mask mandates. “Anybody who tries to tell you, ‘Well, don’t worry about the kids; the virus won’t really bother them,’ – that’s not the evidence. And especially with Delta being so contagious, kids are very seriously at risk and it’s up to all of us to do everything we can to protect them,” Dr. Francis Collins, director of the National Institutes of Health, said Sunday on Fox. Schools in some parts of the country are already struggling with quarantines and temporary closures as infections spread. Many parents are struggling too. That’s why masking is especially important in schools, said Dr. Monica Gandhi, professor of medicine and associate division chief of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/ San Francisco General Hospital. “Remember, we were able to open schools safely in many parts of this country even prior to any vaccinations. We know the mitigation procedures that work, and they are masks and, frankly, ventilation,” she said. Despite 63% of American parents favoring mask requirements for the unvaccinated in schools, and masks being shown to work in study after study, some states – including Florida and Texas – have limited or banned local school districts from requiring masks, leading to showdowns with school boards and sometimes parents. “I know some states have said ‘No,’ but we do need masks during the Delta variant. And then, I believe we need off-ramps for when those masks can come off for kids, because not everyone wants their children masked, and I think that’s fair. But we need off-ramps when the community transmission rate is low,” said Gandhi. “Things seem really scary right now, because cases are increasing rapidly. But this will not continue forever,” Osterholm predicted. “Things will settle down eventually.” He said we can expect to see an uptick in cases as schools go back in session, with larger outbreaks in schools where they do not require masks – but we shouldn’t be surprised by some cases even in schools where appropriate precautions are being taken. “We need to hang on and not freak out … After a few weeks, those will kind of [taper] off and then hopefully things will settle into a manageable pattern, in terms of cases in schools,” he said. Osterholm once again emphasizes the point about the type of masks, saying that kids also need high-quality masks, like KN95, to effectively put the brakes on the “dynamic transmission in children” driven by the Delta virus. And don’t forget about ventilation, stressed Marr. “We need to focus on improving ventilation indoors in schools. And this can be as simple as opening the windows – even opening just one or two windows makes a big difference,” she said. Even if classrooms don’t have windows, Marr said filtration can improve air quality fairly inexpensively. “There’s funding [provided by the federal American Rescue Plan] available to schools now … and a good way to spend that would be to invest in a portable HEPA air cleaner, which you can put one or two of these in a classroom and it can help reduce levels of virus that might be in the air, reducing everyone’s exposure and making a safer environment for everyone,” she said. Passing the test More rapid testing is something Faust would like to see. “We should be integrating rapid testing into our daily lives – a lot more routinely,” he said. Faust is not talking about PCR tests, which are used for diagnosing, but antigen tests for the purpose of screening people. While a PCR test is the gold standard for detecting the presence of virus, the antigen tests can be quite useful in determining if an asymptomatic person is contagious. Anyone who is symptomatic should stay home regardless, but the antigen tests can be useful for someone who feels fine but wants to make sure they are not a silent spreader. Faust said the Delta variant makes it particularly important. “That’s how I got scared about this: I started hearing about people testing positive on rapid [antigen tests] who were vaccinated, and I was, like ‘Whoa! That means not just that are they infected; they’re contagious potentially.’” As a vaccinated person, Faust said he doesn’t want to inadvertently spread it to his child, who is unvaccinated, or an immunocompromised person who may not have mounted an adequate immune response. “So Delta changes the equation in terms of, before I would have advocated [testing] for everyone who was unvaccinated. But now I’m advocating it for everybody,” he said. Faust said that rapid tests got a bad rap early in the pandemic, even from public health experts, because people didn’t appreciate how to use them: They were believed to miss many infections and were considered subpar to PCR tests. “People said that the statistics show that they miss a lot of cases. But that’s actually a misunderstanding of how these tests work. The rapid tests don’t diagnose whether you just got infected or whether you had an infection a week ago – which, by the way, the other tests do. The rapid test only tells you when you’re contagious,” he said. “We can’t let the perfect be the enemy of the good,” he said, noting, “you’re going to miss a case once in a while because you did a rapid test, but in exchange you’re going to catch 50 sooner.” (Here is a list of FDA authorized rapid antigen tests.) Osterholm agreed more “surveillance testing” needs to be done. “Obviously, knowing whether or not you’re positive, whether you’re infected, is so important in minimizing the risk to others by taking responsible actions on your part to limit the contact you have with others,” he said. Marr also put testing on her top five list. “[Testing] is also important because it can catch people … who are infected – and maybe they don’t know it – and help isolate them and keep them from spreading the disease around to other people,” she said. Reassess exposure risk Faust said, given the dominance of the Delta variant, it’s time for Americans to reassess and adjust their risk of exposure if necessary, especially if they eased up on measures in the late spring and early summer. “Delta has changed my risk calculator for myself – and I think it’s good for others [to do],” he said. By way of example, Faust said he took “two completely frivolous trips” to New York City in June. “And I did indoor dining, because the case counts were low and I was vaccinated and regular infections weren’t really happening,” he said. But, given the situation today, he said he would not do the same thing. “Now, my recommendation on travel is to only do travel when it’s really necessary,” he said. That same mindset should be applied to all “risky” activities, from attending weddings and concerts and sporting events, to dining out and travel. And what’s “necessary” will vary from person to person. “I mean, what’s actually really, really important to you – ask yourself: is it worth the risk? Really prioritize,” Faust recommends. There is no doubt we have more knowledge and tools now than this time last year, and with testing, masks and vaccinations, gatherings can be much safer. It comes down to a balance between the importance of the gathering and the tolerance of risk. Osterholm said he, too, is reassessing and prioritizing. “I happen to be a grandparent of five wonderful young kids, none of them are vaccinated. And this has reoriented my thinking to how close contact I have with them,” he explained. He said he doesn’t want to get them sick, so he has scaled back on activities like indoor gatherings with them. “We just have to acknowledge this is a tough time, there are no easy answers … I wish I had better information other than to say that, at least while this Delta variant is very common in our communities, now’s the time again to unfortunately go back to where we were, before the surge, in terms of how we address the issue of being with our kids and grandkids.” Marr, too, said we should be once again setting limits. “If you are fully vaccinated, you are much better protected than you were before. But with Delta circulating … the vaccine is not a get out of jail free card; we still should be taking precautions like avoiding crowds … We still need to be doing these other precautions in order to get past this current wave,” she said, noting she, herself, is “wary” of indoor dining. Beyond the fall It’s hard to know if coronavirus infections caused by the Delta variant will peak and rapidly fall in the United States, like they did in the United Kingdom, or if they will remain stubbornly high. “We are not sure how this is going to play out for the next four to six months,” said Osterholm, pointing out that we are in a critical stage of the surge. “If … the Delta variant follows this pattern that it’s taken in other countries, we can expect to see – particularly the Southern sunbelt states that are getting hit so hard right now – actually show a really rapid decline in cases probably in two to three weeks. The real challenge is what’s going to happen with all the other states where we’re seeing increases … If they too light up, then this surge could actually go on well into mid-September or later.” Regardless of which way infection rates go, Gandhi said we should aim to reduce viral transmission by all means necessary, even in the setting of effective vaccines. “[J]ust the fact that you have more circulating virus alone will make it more likely that you get a mild breakthrough infection. And the problem with a mild breakthrough infection is you can pass on to another and that other person, if they’re unvaccinated, can get sick,” she said. We just have to find the common sense to implement the measures we know to be effective. “Things are tough right now with Delta because we’ve heard how transmissible it is and how people who are vaccinated can carry high loads of virus in their noses. But I think we can be reassured that the vaccines still provide excellent protection against hospitalization, serious cases of illness … We know what works and, [even] with a more transmissible virus, those things still work: the masks, the distancing, ventilation, filtration and avoiding crowds,” said Marr. “We just need to make sure we are even more vigilant about them.” And that is how we dance with the coronavirus. It’s that simple and we already have the tools at our disposal.