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Your questions about covid-19, answered by Dr. Leana Wen

Dr. Leana Wen
 

Public health expert Leana S. Wen answers reader questions about covid-19 every week in her newsletter, The Checkup With Dr. Wen, and in occasional Q&As with readers. We’ve compiled some recent questions below, and will continue to update this page with the latest guidance.

Should I take paxlovid ?

The FDA’s authorization of paxlovid is for individuals who have positive test results and are at high risk for progression to severe covid-19. It must be taken within five days of symptom onset, and should be initiated as soon as possible after the covid diagnosis.

The way I interpret this is that if you are at high risk based on age or underlying health conditions, you should not wait until you have symptoms before you start paxlovid.

Note that paxlovid is not used to prevent people from contracting covid-19. That is, household contacts who tested negative shouldn’t take it thinking that it would stop them from infection (a study found that this doesn’t work). But if these contacts do test positive, and they are at high risk for severe illness, they should take paxlovid to prevent progression to hospitalization and death.

How do I get paxlovid?

“Last week, I was diagnosed with covid. I went to my pharmacy, but the pharmacist said she can’t give paxlovid without a prescription from a doctor. Why not? Doesn’t this prevent people from accessing a treatment that can help them?” — Sam from Illinois

Paxlovid is an excellent treatment for covid-19 for those at high risk from severe disease. It is a prescription medication, and like other prescription medications, requires that a physician (or nurse practitioner or physician’s assistant) to prescribe it.

That said, it is true that anything that adds complexity to the process can serve as a barrier to access. This is why I’ve appreciated the Biden administration’s “test to treat” initiative. There are many locations around the country where people can walk in, get tested and, if it’s positive, see a provider right there and then to determine eligibility for paxlovid. If a person is eligible, the pharmacist dispenses the treatment right away.

What is “paxlovid rebound” and should I be worried about it?

“Paxlovid rebound” is a real phenomenon, and patients need to be aware that it could occur. But the possibility of relapse isn’t a reason to forgo an effective treatment that could substantially lower the risk of severe disease.

Here’s how paxlovid rebound tends to manifest: Someone who tests positive for the coronavirus and is deemed at high-risk for severe outcomes begins the five-day course for the drug. They start improving, test negative and complete their course of treatment, thinking that they’ve beat the virus. But then symptoms reemerge, often around day 8 to 10. Rapid tests that turned negative usually turn positive again.

Such relapse is no doubt bothersome. No one wants to think their illness is gone, only to have it come back. Testing positive again means that person also has to isolate again, which is highly inconvenient.

Pfizer, the manufacturer of paxlovid, initially reported that rebound symptoms occur in about 2 percent of cases. This was only slightly higher than in placebo, which had a 1.5 percent relapse rate. These studies were done during the delta surge. We don’t know the incidence during omicron, but anecdotally, it seems the rebound rate may now be much higher.

Why is this happening? One hypothesis is that there are some individuals who are more prone to prolonged viral replication. The antiviral pill causes an initial diminution of virus, but then it recurs after the five-day course is complete.

Studies are ongoing to find out if the five-day course should be longer. Perhaps patients should instead be prescribed 10 days of paxlovid. Pfizer’s chief executive has also suggested that patients should take the drug again if they relapse, though the Food and Drug Administration quickly refuted him.

Most cases of relapse seem to be mild, and based on the FDA’s statement, I do not recommend a second course of paxlovid for relapse. This guidance could change, but we need to wait for additional studies. In the meantime, people should isolate for as long as they keep testing positive.

The Centers for Disease Control and Prevention says people can go into public spaces after the initial five days of isolation as long as they wear a well-fitting mask. I would clarify that if someone continues to test positive, they should stay isolated from people they live with. Do not share indoor air. If you have to see loved ones, do so outdoors. Don’t dine indoors with your family while your home test shows that you are contagious for covid-19.

None of these adaptations should change our overall outlook on paxlovid. Yes, relapse is an inconvenience, but we’re talking about a treatment that reduces the chance of hospitalization and death by nearly 90 percent. Individuals at high risk for severe illness should not hesitate to take this highly effective antiviral pill.

Should I get a second booster?

I am a 46-year-old type 1 diabetic with no complications. I have no other underlying conditions. I have had three Moderna shots and no covid. I am healthy, but when I get a flu or cold, I am always a little sicker then everyone else in my family. Should I get the fourth shot? — Anonymous

Technically, you are not in the groups currently eligible to receive an additional, fourth covid-19 vaccine. According to the CDC , those groups are:

  • People with moderate or severe immunocompromise. A list of conditions can be found on the CDC website. They include organ transplantation, active cancer treatment, and being on high-doses of immunosuppressing medications. (Diabetes, while it can increase your risk of severe outcomes from covid-19, is not one of these conditions.)
  • Adults over 50 who received three doses of either mRNA vaccine (Pfizer or Moderna), and who are at least four months out from the last vaccine dose.
  • Adults (regardless of age) who received the Johnson & Johnson vaccine first and then a J&J booster. If they are at least four months out from their last vaccine, they can receive a second booster dose with an mRNA vaccine (either Pfizer or Moderna).

Now that a second booster is being made available, I think we need to continue to remind people that this doesn’t mean the initial vaccines don’t work anymore. Vaccines plus the initial booster still provide excellent protection against severe illness due to covid-19.

“Should an obese person, mid-30s, pre-diabetic get the second booster shot? Is it allowed under the new guidelines? Person also suffers from mental illness and takes medicines for it.” — Bob from New Jersey

The Food and Drug Administration and the Centers for Disease Control and Prevention are not allowing for people under 50 to receive a second booster dose, unless they are moderately or severely immunocompromised (which this person is not). Given this person’s age, they are not eligible for the booster at this time.

You mentioned obesity, pre-diabetes and mental illness. All of these could predispose to more severe outcomes. I encourage this person to find out from their physician what exactly their risk is based on their specific medical situation. Now is the time to optimize other elements of their health, including, in this case, to prevent pre-diabetes from progressing to diabetes.

“I am a 71-year-old health-care worker. I’ve been fully vaccinated and boosted as of October 2021. I am invited to an indoor family dinner in New York City to be attended by several households. Do you recommend a second booster before I go?” — Dorothy from New York City

I recommend a second booster based on your age. The booster will reduce your chance of getting covid-19 for at least several weeks, but this alone is not the only tool available to you to increase safety at the family gathering. Would the others attending be amenable to requiring vaccination and same-day rapid test? Those measures would make the gathering much lower-risk.

“I am weighing the options of getting a second booster shot now or waiting for the omicron-specific booster, partially for safety and partially for monetary reasons. Is this an either-or choice? If I get the second booster now to enhance current protection, will it preclude my ability to obtain an omicron-specific (third) booster when it becomes available? And would it still be free to me? I’m 70 and in good health and have had two Moderna vaccines and a Moderna booster.” — Christina from Washington

I think you should take cost out of the equation. The Biden administration has committed to making vaccines and boosters free for Americans. I don’t think this will change anytime in the near future. (Note that lack of congressional funding has resulted in the uninsured being billed for testing, and there is uncertainty around whether covid-19 treatment will remain free for them. This is a major problem, but I still do not expect that anyone will be charged for vaccines in the near future, given that vaccination is the single most important key to ending the pandemic.)

Based on your age, I’d recommend getting the second booster now. The one exception would be if you just recovered from omicron, in which case the chance of reinfection is low. You could probably wait a little, as that infection was, in essence, a booster.

There is also no reason to believe you would be ineligible for an omicron-specific booster, should one be authorized, just because you got your booster now. For someone your age, I would not recommend waiting for the variant-specific booster; I’d get the second booster dose now and then consider the next booster once it’s authorized.

“I’m 72 years old with several preexisting conditions (high blood pressure, obesity, diabetes and smoking). I’ve had my two vaccines and got my first booster seven months ago. In July, I will be traveling for the first time to California for the birth of my first grandchild. Should I get my second booster now or closer to my travel date?” — Rhonda from Illinois

Congratulations on becoming a grandmother soon!

I would get the second booster now, given your age and preexisting conditions. The data are quite clear that people over 60 would benefit from a second booster at this time, unless they recently recovered from an omicron infection. Your other medical conditions make you higher-risk, too. I would not delay the booster.

When you travel, depending on the coronavirus transmission levels at that time, consider adding more protection. For example, wear an N95 mask or equivalent while at airports and on the plane. Avoid indoor restaurants. Consider asking others you will see at the birth to take precautions for you, such as testing right before being together indoors.

“My college-aged son is going abroad next week for the summer, where he will be on an archaeological dig with a group of other college students. Our healthcare providers (Kaiser) would not give him a second booster, nor could he get one at CVS. Should he push to get one?”

Your child is presumably under 50, and therefore is not eligible to receive a second booster. Unless he is moderately or severely immunocompromised, there is no medical reason for him to receive one. He is very well-protected from severe disease to covid-19.

When will fourth doses be available to all?

“When will those under 50 be approved for a 4th dose of the vaccine?” — Tara

People who are immunocompromised are already able to receive a fourth dose. I’d look for recommendations for all adults coming into the fall. By then, we’ll have more information about how quickly immunity against infection wanes for those who are younger and generally healthy.

“Is there any indication that the CDC will expand eligibility for a second booster shot? I have multiple risk factors (heart condition, diabetes), but I am not considered ‘high risk’ enough under the current eligibility guidelines.” — Trevor from Nebraska

Adults 50 and older are eligible for a second booster dose. People at high risk include those who have risk factors such as yours (CDC’s full list of underlying conditions that predispose to severe covid-19 is here). If you are 50 and older, you would qualify for that second booster dose. You’d also qualify if you are moderately or severely immunocompromised.

Some people have asked when eligibility for a second booster will open for adults under 50. I expect this will happen before the fall, in anticipation of a possible surge in colder months.

Should I wait for a variant-specific booster?

“My wife (69) and I (74) have been vaccinated with two Moderna vaccines. We received the Moderna booster in October 2021. We are generally healthy and have had no known covid infections, although some of the folks we’ve been in contact with have. Does it make sense to get a second booster at this time, or should we wait for the more omicron-specific booster Moderna has in trials?” — Richard from Massachusetts

I’d recommend that you and your wife get your second booster now, given your age and the fact that it’s been seven months since your first booster. The evidence is quite clear that immunity — including to severe disease — wanes after six months for those 60 and older. If an omicron-specific booster were to be made available in the future, you would still be eligible for it then. I wouldn’t wait.

“Is it better to wait for a new covid-19 vaccine that will be more targeted to the new strain? I am in my 70s and immunocompromised. Already had two vaccines and one booster.” — Ellen from New York

You are in a different situation from the reader above. People who are moderately or severely immunocompromised have two major risk factors: First, they might not produce as much of an immune response from the vaccines. Second, they are at an elevated risk for severe illness if they contract covid-19. Therefore, this group should receive the additional booster now.

Your age is another risk factor. I would lean more toward your getting the booster shot by age alone. In combination with immunocompromise, I would not advise waiting. (Of course, speak with your physician about your specific medical situation.)

There are omicron-specific boosters and vaccines that are being studied. Those data might take weeks to come out, and by the time authorization comes around, it could be months. For some people, it would be reasonable to wait. For you, with both age and immunocompromise, I’d be in favor of getting the fourth dose now. Then you can receive the variant-specific booster in the future if needed.

“I had COVID-19 in May. When should I get my 4th booster shot? Should I wait for the omicron-targeting shot?” — Susan

Conventional wisdom is that you have a “grace period” of about 2-3 months during which reinfection is unlikely. You could wait until this period is over before getting your second booster. It’s possible that by then, there will be a booster authorized that targets omicron.

Should I get the Novavax vaccine when it’s authorized?

“I am an individual with multiple health risks, and quite terrified of covid-19. I am vaccinated and double-boosted with Pfizer. The Novavax vaccine is an entirely different approach from the mRNA vaccines. Does it make sense for me to also consider it when it’s approved? I’d like to feel confident getting on an airplane again.” — Jim from Washington

I think there are two different issues here. First, I agree with you that the Novavax vaccine is promising. As you state, it is a different platform than the mRNA vaccines, and it’s likely that a “mix and match” approach with different vaccines can diversify and therefore further enhance immune protection. It is not yet authorized by the Food and Drug Administration, but if and when it is, the Novavax vaccine could be a good additional option for future boosters.

Second, you seem to be concerned about air travel and, by extension, the risk of other in-person interactions. Vaccination is one important tool, but it’s not the only one. Wearing a well-fitting N95 or equivalent mask and keeping it on the entire flight will protect you well during air travel.

I’d also advise that you have a plan for what happens if you contract covid-19. With your health risks, you probably qualify for antiviral treatments, monoclonal antibodies or remdesivir. These treatments further reduce the likelihood of severe illness due to the coronavirus. Knowing how to access the treatments should also help you to reengage in the activities you love.

How often do I need a booster?

“Would getting boosted every 8 weeks or so be beneficial and safe?”— Michelle

We have to go back what is the purpose of vaccination. The primary reason is to reduce severe illness. These covid-19 vaccines do this, and effectiveness against severe illness is still strong many months later. The effectiveness against symptomatic illness wanes, but it’s not a sustainable solution to boost every time this appears to decrease.

There is another part of your question, which is, would getting boosted every 8 weeks be practical? The answer to that is no, for the vast majority of people. Frequent boosters are not a good public solution. We need better vaccines—such as nasal vaccines and vaccines that cover more variants—not more frequent ones.

Can I get other vaccines at the same time as mRNA vaccines?

“I received my first shingles shot six weeks ago. I can get the second shot in one week, although there is a long period in which to receive it. I also have been vaccinated and boosted against covid-19, although I have not had the second booster yet. Should I get the second covid booster first, or the second shingles vaccine? I understand that you must wait at least three weeks between shots.” — Karen from West Virginia

You can get the coronavirus booster at the same time that you get the second shingles shot. The Centers for Disease Control and Prevention explicitly says this and also makes the recommendation that you use different injection sites for the two shots — preferably different arms.

How can I get my vaccine dose registered?

“I received my initial two doses of the Pfizer covid-19 vaccine at a walk-in military immunization clinic, my first booster at a pharmacy and my second booster at a scheduled health department clinic. Only my last dose was registered in the Maryland immunization database. How do I get my other two doses registered? I hate the idea that the only proof I have is my little white card.” — Deirdre from Maryland

Different states have different protocols for their immunization databases. In Maryland, pharmacies, local health departments and health-care providers are all able to enter information into the database. Consider asking your primary-care physician to update your record for you. Your local health department might be able to do that, too.

Many people probably wouldn’t go to the trouble of doing that. In that case, make sure to have a copy of your immunization card. Take a picture and keep it on your phone and computer. For additional safekeeping, consider sending it to a close friend or family member, and make sure your doctor has a copy, too.

How do I know if I’ve had covid-19?

“I’m immunocompromised, and my husband recently had covid-19. We had spent the whole day together before his symptoms started, in a closed car, maskless, talking, eating meals together. I never got it! I also worked out at a gym maskless, though it’s a big space without too many people. I wear masks in public indoor spaces, but I’ve been out for dinners, socialized with small numbers of friends. Everyone around me seems to have had it, but I haven’t gotten it yet. I’m vaccinated and twice boosted. Is it possible that I’ve had the virus already? I’ve had some colds over the last two years but never longer than a few days, and I’ve been tested many times and never tested positive. What gives?” — Leah from Vancouver

The CDC estimates that by the end of February, about 60 percent of Americans have had covid-19. That’s more than double the official count, and it means that many people may not have realized that they had the coronavirus.

It’s certainly possible that you are in this group. Perhaps you had an asymptomatic infection. Perhaps you had symptoms, but at the time you tested, the test had not turned positive.

You could ask your physician for an antibody test if you are curious. Many commercial laboratories offer antibody tests that specifically look for the nucleocapsid protein, which would be positive if you have previously had covid-19. This is different from the test to detect antibodies produced by the vaccine.

Keep in mind that just because you’ve had covid-19 before doesn’t mean that you can’t get it again. And if you test negative, perhaps you’ve been fortunate thus far to avoid it, but you could still get it in the future. Given your immunocompromise, I’d still advise caution, while continuing the activities you enjoy.

What are the chances of asymptomatic transmission?

“If you are vaccinated and boosted, what are the chances of asymptomatic transmission? I am debating going to a large professional event, and because there will be eating and drinking I will not be able to mask the entire time. I am concerned about transmitting the virus to my young child, who is not vaccinated yet.”

Asymptomatic transmission can occur in individuals who are vaccinated and boosted, though the chance of someone contracting covid-19 is still less than if they were unvaccinated. One option is to go to the professional event, mask for three days after returning, and then testing before unmasking around your child (though this is very challenging around a young child!). An easier option might be to go to the event and skip the eating/drinking portion, and wear a high-quality mask yourself the whole time when around others.

Can exposure without infection be protective?

“After 2.5 years of successfully avoiding covid-19 infection, my vaccinated and boosted 20-year-old tested positive. My husband and I (vaxxed and doubled-boosted) were both exposed to her as she was becoming symptomatic, yet we never got sick and never tested positive. Do we gain any protection from this exposure? Does the fact that our immune systems resisted infection mean that they are primed to respond equally well if we’re exposed again? Or was she not shedding virus in enough amounts?” — Becky from Maine

The short answer is that we don’t know. It’s possible that your vaccines were working exactly as they should to keep you from getting infected. It’s also possible that at the time of exposure, your daughter was not transmitting enough virus to be contagious.

If you were infected, you would have a period of time — probably around three months — during which you would be unlikely to become reinfected. But I would not consider an exposure as protection against other exposures in the future.

What don’t we know about the BA.2 variant?

What are the biggest questions about BA.2 that are not yet answered? In other words, what are the current limits of advice? What are researchers trying to discover? What may soon become more clear? — Anonymous

Excellent question! A lot is already known about BA.2, including that it does not appear to be more virulent than the original omicron and that it still responds to existing vaccines (I wrote more about what we know in this op-ed). Here’s what I really want to know — not just about BA.2 but more broadly about covid-19:

  • What’s the true prevalence of long-haul covid? Can we define severity of symptoms, and how common is it to get mild, medium, and severe long-covid?
  • How common is long-covid with reinfection? How common is it with omicron (including BA.2)?
  • Are there good correlates of immunity that we can use for clinical decision-making? For example, can antibody levels be measured in order to determine whether someone needs a booster at this time?
  • Will variant-specific vaccines work better than the original vaccine? And what treatments can be available specifically to treat long-covid?

Do we have an accurate count of covid cases?

“With so many people self-testing and the elimination of contact tracers in most areas, how do we have an accurate count of covid-19 cases? People I have spoken with who test positive with a home test say they are not reporting it to any government agency.” — Marjorie from New York

The number of reported covid-19 cases is a substantial undercount. It has been that way during the entire pandemic in the United States. Initially, and during some surges — including the omicron surge — this was because of a lack of testing. More recently, it’s also because of home tests that are not reported to local health departments. In addition, many health departments are switching to weekly reporting, so increases might not be reflected in real time.

This is why I support the surveillance efforts taken by the Centers for Disease Control and Prevention, including wastewater sampling. People with the coronavirus shed it in their feces, and studies have shown that virus levels in community wastewater rise days before an increase in positive tests. This type of early warning signal is essential going forward to mobilize resources ahead of future covid-19 surges.

“In the past six weeks, I’ve personally known or have heard about at least 50 people who have had covid-19. I doubt anyone has reported their case. Most cases varied from very mild to flu-like aches and fever and were diagnosed by home testing. What do you think about this lack of reporting?” — Susan from Vermont

You are right. The vast majority of home antigen tests are not being reported to health authorities. The actual number of positive tests is probably five to tenfold higher than the released statistics.

To me, this calls for better surveillance testing as a proxy for the level of covid-19 in communities. Months ago, the CDC announced that they would be test communal wastewater to detect viral surges as early as possible. Institutions that do random sampling of asymptomatic individuals should also report their data to health authorities. For example, many hospitals test all patients before surgery. If many asymptomatic individuals start testing positive, that’s a sign that there is a surge underway. These kinds of numbers become more important to track as home tests proliferate.

Which type of coronavirus test should I get? What’s the difference?

“I am getting confused about which kind of covid test I should get. What is the difference between the home covid tests and the tests from testing sites?” — Anonymous

There are two types of tests that one can take to find out if they have the coronavirus. (A third exists, too, the blood antibody test, but that only looks at whether you have been exposed to the coronavirus through vaccination or infection, and is not useful to find out if you currently are infected).

These two tests are the PCR test and the antigen test. PCR is the gold standard and is generally the one available at testing sites (though some offer rapid antigen tests too). If you go for a PCR test and it’s negative, it’s very unlikely that you have covid-19. However, it is so sensitive that it picks up the virus for a long time — so it may be positive even weeks after you have already recovered. It’s therefore not a good test to use if you want to find out if you are still infected after your symptoms improve, because it may still be positive even if you are no longer infectious.

The rapid antigen test is the typical home test. The advantage is that the results come back immediately, within 15 minutes or so, compared to the PCR test, which could take hours to days. The disadvantage is that the antigen test is less sensitive. A positive antigen test is almost certainly a real positive, but a negative antigen test may be a false negative. Antigen tests perform best when done serially, meaning that if you have two negative tests, a day apart, then it’s more likely to be truly negative.

What test you get depends on what you are using it for, and how easy it is to get one. Don’t use the PCR test to find out if you are cleared from being infected, for example. Know that an antigen test isn’t perfect, so if you are symptomatic and it’s negative, you may still consider getting a confirmatory PCR test.

Are covid tests effective before symptoms start?

“I have read that at-home covid-19 tests are not effective until you begin to show symptoms. If true, then testing before and/or after a gathering where people are not masked could give inaccurate negative results. So is there really value in testing in those situations?” — Bill from Washington

This is not true. Plenty of people are asymptomatic and test positive on at-home rapid antigen tests.

It is true that PCR tests are more sensitive than antigen tests and can generally pick up infections earlier, and that they will continue to be positive for longer. The primary value of antigen tests is that they tend to be positive at the point that people have a high enough viral load to be contagious to others. That’s why it’s so important to take the test as close to a gathering as possible. If you tested negative two days ago, you could be contagious today, but if you tested negative an hour ago, it’s unlikely you have a high enough viral to infect others.

I’d recommend requiring attendees of a gathering to test just before they leave for the event or just as they arriving, ideally within a few hours of the get-together. Testing after a gathering should mainly be done to protect others. For instance, someone who went to a higher-risk event, such as a crowded maskless wedding, and wants to have dinner with an immunocompromised relative should test right before that meal.

How long after contracting covid will I test positive?

“My father-in-law is still testing positive on day 13 after his first positive test. He hasn’t had symptoms for more than 10 days. Is he still contagious? How long do people still test positive and what does it mean after 10 days?” — Alex

Most people test negative after 5 days. The vast majority will test negative after 10. However, some take longer to clear the virus. It’s not understood why this is the case. There may be some correlation between severity of disease and degree of viral load exposure, and those with immunocompromise may also take longer to turn negative; however, some generally healthy people with mild symptoms could also be testing positive for more than 10 days.

I want to clarify, too: Is your father-in-law taking rapid home tests? PCR lab tests can stay positive for quite a long time — even weeks — after someone’s diagnosis. The home antigen test is a better indicator of the infectiousness of someone who has covid-19. Someone diagnosed with covid should get rapid tests, not PCR tests, to see when they can exit isolation.

I hope he tests negative soon!

Which type of mask should I wear? What’s the difference?

“There are several different types of masks. Cloth masks can be reused, but they may not be as effective as N95 masks. Is it possible to use different types of masks for different settings? For example, ’better’ masks for school, which lasts 6 hours, and ‘cheaper, reusable’ masks for quick trips to the supermarket.” — Anonymous

This is a reasonable question, but I think it’s based on an assumption that the “better” masks — the KN95/N95s — are not reusable. They are. I answer how below.

At this point, given how contagious omicron is, I would advise that you put on an N95 or KN95 if you’re going to wear a mask at all. If you find these masks really hard to tolerate, consider trying on different types.

If they are still very hard for you, then yes, you could limit their use to the highest-risk settings and then use a more comfortable mask for lower-risk settings.

“Is there a difference between wearing an N95, a KN95 or an N94 mask?” — Anonymous

The N95 is the American standard. The KN95 is the Chinese standard, and the KF94 is the Korean standard. They are all fairly equivalent when it comes to protection. Use the mask that works best for you in terms of comfort. Here’s a good article about how to make sure you aren’t purchasing a counterfeit. In short, buying from a well-known supplier directly helps (for example, 3M, Kimberly-Clark). Project N95 is also a fantastic resource.

How many times can I safely reuse my N95 or KN95 mask?

“Can N95 masks be hand-washed in scalding-hot water with detergent, air-dried, and then reused? – Harry from Maryland

No, please don’t wash your N95 mask. These masks have special electrostatic fabric that could be disrupted with water and detergent. They can be safely reused without washing. My recommendation is to have at least three N95 or equivalent masks that you use in rotation — one today, the next tomorrow, and so forth, no cleaning necessary. If they get wet or lose their shape, it’s time to throw them out.

When is it safe to lift mask mandates?

“I am a board member of a community chorus of about 50 people. We require singers to be vaccinated and boosted, and we’re currently rehearsing while wearing KF94 masks. What local conditions would signal that we could make masks voluntary? I estimate the average age of the group is above 60 years.” — Raymond from Florida

The Centers for Disease Control and Prevention issued new guidance on Feb. 25:

If your area is in red, masks should be required, because singing is a relatively high-risk activity, especially if done indoors, in close proximity to one another, without masks. If it’s in green, you do not need masks.

If your area is in the yellow zone, you could consider the “two out of three” rule. All your singers are already vaccinated and boosted. If you want to go maskless, the safest option is to have everyone test before singing.

Another option, as you suggest, is to make masks optional. Masking with a high-quality mask such as KF94s protects the wearer well regardless of what others are wearing (though there is even better protection if everyone is masking). Consider having a discussion with members of your choir. How strongly do they feel about continuing to mask? Will some refuse to participate if others around them no longer mask, or is everyone fine with the potential risk? If the entire choir thinks one-way masking is a reasonable compromise, you might consider optional masking even if community transmission has not fallen to the green zone, though the safer option is to wait just a bit longer for rates to fall further.

Does this new variant mean mask mandates in schools should be returning? — Anonymous

In my view, no. I agree with the CDC’s recent change to masking guidance, which aligns mask recommendations for schools with the surrounding community. When the risk of covid-19 is low and medium, masks do not need to be required, including in school. This new subvariant of omicron is more transmissible, but does not cause more severe disease and still respond to existing vaccines. I do not think societal restrictions need to come back, though we must carefully watch for signs that our healthcare system could come under excess strain and be ready to add back in protections if needed.

Which vaccines are most effective?

“Why would any parent give their kid Moderna when Pfizer is more effective? And even two doses of Pfizer might be better than Moderna. We do not know.” — Tom

The Pfizer and Moderna studies were not done head-to-head. It is not possible to compare them and say that one is more effective than the other.

In addition, the Pfizer numbers may look better for preventing infection at the moment, but they are preliminary and based on only 10 positive cases.

Even if it turns out that Pfizer has the edge for effectiveness in preventing infection, there is still a case to be made for choosing Moderna. A lot of parents may not want to wait for all three Pfizer doses in order for their child to be fully vaccinated. They may opt for whatever is the highest level of protection they can receive the fastest. I think it’s important to give parents this choice.

How long do I need to isolate if I test positive for covid-19?

“My husband tested positive. He isolated for five days. His symptoms were those of a common cold. On the sixth day, he used a rapid test and did a PCR test. Both came back positive. The nurse with his insurance company told him he could keep up his doctor’s appointments and he could end the isolation as long as he wore a mask at all times. We were both surprised at this recommendation, but based on that information, he went to the orthopedic doctor for a follow-up as he had fractured his wrist. Was this sound advice?” — Carmen from D.C.

According to new guidelines from the Centers for Disease Control and Prevention, your husband should have stayed in isolation and not gone out in public.

To be fair to the nurse from the insurance company, the CDC guidelines are confusing and, in some ways, contradictory. They state that people diagnosed with covid-19 should isolate for the first five days; then, for the five next days, they can go out in public as long as they wear a well-fitting mask. But the guidelines also say that if someone tests positive after five days, they should keep isolating. (If it’s negative, they can be out in public as long as they are masked until day 10).

The guidelines seem to suggest that there’s basically no purpose to testing. After all, if you can go out after five days without a test anyway, then why bother getting a test at all? As they read now, testing seems to be disincentivized, because someone who gets a positive antigen result after five days shouldn’t be out in public, even with a mask, which is more restrictive than if they never got a test. (Note that PCR tests can stay positive for weeks or even months after an infection, so a PCR result is not recommended for the purposes of ending isolation.)

Given the head-scratching CDC recommendations, my advice for the future is to ask the doctor’s office you’re visiting directly. Many offices will not allow people to visit who had covid-19 so recently for fear of infecting staff and other patients, especially if someone tested positive that same day. In the meantime, I hope the CDC will clarify its isolation guidance.

“I had a fever one evening, and the next morning a home test was positive for covid-19. Because I’m 69 years old (otherwise well and on no medications), I took paxlovid for five days. The fever resolved after two days, and I’ve felt well. But on day 6, I did another home test (before visiting my 18-month-old granddaughter), and it was still positive. I have resumed isolation. Assuming I continue to feel well, how long should I isolate? Can I travel as planned six days from now? I would mask in any case.” — Jerome from Maryland

Many people still test positive after five days, regardless of paxlovid usage. The CDC says that people are able to stop isolation after five days as long as they wear a well-fitting mask in public places for the next five days (and they have no fever and symptoms are resolving). You could, therefore, travel as planned, as long as you mask.

However, I do not think this CDC guidance is complete. I would strongly advise that you do not visit people indoors or go to indoor settings where you will be maskless, until you test negative by a home test. A rapid antigen test reflects whether someone has a viral load and therefore is probably still contagious. Don’t visit your granddaughter indoors, go to a restaurant and so forth until your home test is negative. (Note that PCR tests could stay positive for weeks, so this advice is only for the home antigen test.)

“My daughter and her family have Covid. How long would it be prudent to wait after they test negative to gather indoors with them?”— Alice

If everyone in the family all test negative for two days, and are no longer symptomatic, it would safe to gather indoors with them.

What are your recommendations for cleaning after a covid infection?

“My double-vaccinated and boosted 17-year-old daughter tested positive for covid-19 the day after I came home from major surgery. She promptly left to self-isolate, but how long afterwards should her bedroom be considered a danger zone? If we are actively ventilating by opening windows, will that be enough, or are linens and surfaces a concern? Should she be the only one to touch and clean her stuff, now that she has recovered and somewhat super-immune? And given her immunity, after 10 days, will I still need to stay away from her or is she now safe to be around?” — Randall from Philadelphia

Your daughter should self-isolate until she starts testing negative by rapid home antigen tests. The Centers for Disease Control and Prevention says that she could end isolation after five days if she wears a mask for five more days, but I think you should be even more careful than this. Do not have her in the same room as you or other household members until she tests negative.

The CDC has additional guidelines on how to think about timing. It says that if three days have passed since the infectious person was in a space, no specific cleaning is necessary. If it’s been between 24 hours and three days, surfaces should be cleaned but not disinfected. If it’s under 24 hours, use disinfectants and wear a mask during the cleaning.

I agree with these guidelines and would add the following as it applies to your situation. If your daughter is testing negative, you don’t need to stay away from her. You could wait another 24 hours to be sure, then, if she is still testing negative, you can open her room and ventilate it. The easiest thing to do from a cleaning perspective is to have her clean her own room. Surfaces are unlikely to transmit the virus, but to be extra safe, have her wipe down commonly used surfaces such as doorknobs and wash her linens.

How can caregivers protect young children from infection?

“We have a baby boy coming in early May, and I am wondering what precautions we should take for babysitters and relatives who will be in close contact or caring for our baby. We are all vaccinated minus our 4-year-old, who is not eligible yet, and we also had covid-19 in February because of a school exposure. I know the world seems to be taking the virus less seriously now, but we are concerned for our newborn even though he might have some antibodies from me having it while pregnant.” — Christine from Pennsylvania

A big congratulations to you, Christine!

Because newborns have limited immune systems, they are more susceptible to other pathogens, and it’s generally a good idea to use additional precautions. Your baby may have some level of immunity from your covid-19 infection, but we don’t know how protective that immunity will be and how long it will last.

I’d recommend being cautious in the first six months — and in the first month in particular. One thing you could do is recommend that everyone who visits your baby be up to date on their vaccines — meaning that they receive boosters if they have not already. That would reduce their chance of being infected and then transmitting the virus to your baby.

If you have ready access to rapid tests, you could also ask everyone caring for the child or who comes in close proximity to test beforehand. If those individuals are longer-term caregivers — for example, if they are babysitters who are coming multiple days in a row — consider asking them to limit their exposures for a few days before and while caring for your child. For that period of time, are they willing to forgo indoor restaurants and to make sure to mask up in crowded indoor spaces?

Note that these steps might not be practical. You might need to weigh the benefit of having caregivers who aren’t taking precautions vs. the potential risk to your baby. As your baby gets older, the risk will fall, so you could consider having strict protocols for the first month and then loosening them over time.

“What should an 8-month-old baby do on an airplane when those around are not required to mask? Should we try to keep the baby under a blanket?

Place the baby in the window seat if that’s an option. Turn on the air nozzle at full blast to further increase ventilation. Try to keep the baby under the blanket during the highest-risk portions of the flight (boarding and deplaning). Good luck with your travel!

“What do you think about attending outdoor kids’ birthday parties during the omicron surge? My child has been invited by a kid from their prekindergarten class. We are in a place where you can be outdoors in January. The kids mask at school in their age group. I know outdoors is safer, but what would you do? The positive test result is about 40 percent, and I’d assume all kids are unvaccinated due to age. I don’t know the party size or how many guests outside of the pre-K community would attend.” — Laura from Texas

I would go. In fact, I have been going to the birthday parties of my pre-K son’s friends when they are held outdoors, and we live in an area where outdoor events are not too pleasant at the moment.

The way I consider the trade-offs is as follows: First, the risk of outdoor transmission is very low. At the same time, I want to maintain as much socialization as possible. I’m okay with the risk-benefit trade-off and would be happy to have the kids play maskless, in proximity, outdoors. I would stay away from indoor gatherings with a lot of unvaccinated people, and I’d urge using your best judgment the day of, too. If you go and become uncomfortable because there are too many people crowded together in a small space, bow out early. Otherwise, I hope and your child attend and have a great time.

“I know you have at least one child under 5, who is too young to be vaccinated. Given the benefits of vaccines, I wonder if you have an opinion on the ‘off-label’ use of the Pfizer pediatric vaccine (10 mcg) in this age group. I have a 4-and-a-half-year-old, who I would love to have immunized before a long-delayed plane flight at the end of March.” — Scott from Michigan

I also have a 4-and-a-half-year-old, as well as an almost 2-year-old. I would not recommend for younger kids to receive the dose that’s been authorized for the 5- to 11-year-old group. Rather, I’d urge continued caution during the plane trip. Hopefully, it will only be a matter of a month or so before a vaccine for younger kids — at the appropriate dosage — will be authorized.

“Like you, we have two children under 5 years old who are too young to be vaccinated. We have been extremely cautious throughout the pandemic, but our kids do go to preschool (masked) three mornings a week. During the omicron surge, a few families we know did get covid-19, but we’ve been lucky. Is it safe to have unmasked indoor playdates with families that have recently recovered from covid-19 and presumably have some level of immunity for a few months, or should we stick with outdoor playdates?” – Natalie from Oregon

Recovery from infection does convey protection for at least a short time, on the order of a few months. It’s unlikely that the families you know will be reinfected now if they just recovered from omicron. If they all reside in green or yellow areas according to the CDC tracker, I would feel comfortable getting together indoors with families with recent, confirmed coronavirus infection.

“We have a long-planned (and several-times-delayed) trip to Texas for my 6-month-old son to finally meet his family in May. We are visiting high-risk great-grandparents, so I’m worried both about my son catching the coronavirus and picking it up and bringing it to them. My son has not been exposed to the virus yet (although he presumably has some antibodies from my pregnancy vaccination and the booster while nursing), but it seems very risky to bring him on a four-hour flight with unmasked people. Given the frustrating end of mask mandates on airplanes and other transportation, do we need to cancel? If not, what should we do to keep him protected on the plane?” — SoRelle from D.C.

Many parents of young children feel left behind. A vaccine is not yet available for kids under 5, and the end of mask mandates means that these parents feel less safe in public spaces.

It sounds as though you are concerned about the plane trip because you’re worried both about the danger of your 6-month-old catching the coronavirus as well as the risk that he could transmit it to his vulnerable great-grandparents. The trip has some risk, but there are ways to reduce it.

Frankly, even before airplane mask mandates ended, there was risk to young children who are unable to mask themselves. The ubiquitous cloth mask is not very protective, and a lot of people have been lax about wearing facial coverings at airports and on planes. It’s common to see people unmask for long periods of time on flights, claiming they are eating and drinking. Others let masks dangle below their noses or chins.

My point here is that I don’t think the end of the mask mandate should be the factor that makes you cancel the trip. The risk is probably a bit higher now that more people will likely be unmasked, but the risk was already high before, too.

There are things you can do to reduce your baby’s risk. The highest-risk times are not during the flight, when there is good air exchange and ventilation, but in crowded settings at the airport and during boarding and deplaning. Try to limit your time in these settings. Call ahead and check with the airline to see if you can skip the line waiting to board. Before boarding, find a seat far away from others. On the plane, put the baby in his car seat in a window seat. Turn the air nozzle up to full blast. When deplaning, keep the baby in the window seat until it’s your turn to leave.

These steps won’t prevent all risk but will help reduce it. You can then take daily tests (and ask other relatives to do the same) during the visit and ask everyone to avoid higher-risk settings such as indoor restaurants while you are seeing one another in Texas.

I hope you have a good trip and a fantastic reunion.

“I’m divorced, and my 12-year-old lives in two households. Recently, while at his dad’s, he and his dad both had close contacts with someone who tested positive the next day. My son is staying at his dad’s for five days and will test then. My question is what if his dad gets symptoms or tests positive? Should I bring my child back to my house? He and I are both vaccinated and boosted. I’m almost 60 with asthma and double-boosted. I think this answer will be helpful for other single parents, too.” — Jessica from California

The key question here is: Whom are you trying to protect from covid-19 the most? If you are the person most vulnerable to severe effects from the coronavirus, it would make sense for your son to stay with his father even if his father tests positive. Your son’s dad should isolate immediately. Your son should not see you until he has a negative test five days after his last exposure to his father.

If the person you are trying most to protect is your child, then you should take him home immediately, regardless of whether his father develops symptoms or tests positive, because you wouldn’t want to risk that infection. His dad could still be transmitting covid-19 before he becomes symptomatic.

The situation would also be different if your child were younger. A 12-year old can be fine alone for most of the day, but a 4-year-old can’t exactly fend for themselves. In either case, I’d still ask the question of whom you are trying to protect the most in the mixed household, and work to reduce risk for that person.

Why should I vaccinate my child?

“My husband is a data scientist, and he still has vaccine hesitancy when it comes to vaccinating his 4-year-old son (my stepson). I am urging him to speak to his pediatrician, but he is not convinced that the benefits of the vaccine outweigh any risk of side effects for a 4-year-old. He is also not convinced that covid poses much of a risk to a young child. I would like his son to get the vaccine. What would you say to his risk-benefit analysis?” — Hilary from California

I’ve written several columns explaining my thinking about the risk of covid-19 to my two young children and the benefit of the vaccine for them. One major fallacy all along has been that the coronavirus somehow isn’t a risk for kids. Just because it causes more severe disease in adults doesn’t mean that it isn’t potentially dangerous for children; in fact, more than 400 kids under 5 have died and thousands have been hospitalized.

Those numbers may seem low to some, but we give routine pediatric vaccinations for many other illnesses, such as rubella, hepatitis A and rotavirus, that cause far less death than covid-19. The point is to prevent disease, especially when there is a vaccine that is very safe.

For me, the risk-benefit calculus is easy. At most, my children will have a day or so of fever and crankiness. I would willingly take on this potential risk to have the benefit of them being spared severe illness from covid-19.

And, in fact, I’ve done this — both of my kids received their first doses on Monday.

When should I vaccinate my child?

“Should kids under 12 get a booster shot now or wait for the school year? Do boosters really add protection for children under 12 when the current strain is so mild especially for those vaccinated?”— Rosa

Good question! I just wrote about it in this column. In short: the answer isn’t straightforward, and depends on your family’s specific circumstances.

“My child will be 5 at end of July. Should I wait until their birthday to get my child vaccinated with a higher dose vs getting the under 5 now?”

Great question. It’s one that I have too — my son turns 5 in August.

I expect the CDC will be weighing in on this question in their deliberations today and tomorrow. I think they will give the same advice as they did for 11-year-olds who are about to turn 12, which is to say not to wait. Get the vaccine now that correlates with the current age. If their next dose is due after their birthday, they’ll get the higher dose then. That’s what I plan to do. I’ve waited long enough and am not going to delay my kids’ vaccinations anymore.

“Do you have a good sense of how many of your colleagues in the medical establishment will be vaccinating their children under 5 in the coming weeks? — Jesse

Hi Jesse, anecdotally, every single of my physician-mom friends with young kids plan to vaccinate our little kids ASAP. The vaccines are safe and the evidence is very clear that they are effective–they induce very strong antibody responses that are comparable to the antibody responses in adolescents and young adults. (I wrote more about my thinking in this column).

“My baby has already received the first dose of the Moderna vaccine and has an appointment to return for the second dose in four weeks. However, I am hearing that other pediatricians are recommending waiting six to eight weeks between doses to increase effectiveness. What are your thoughts about the ideal time period, assuming it would be reasonable in terms of exposure to wait longer for the second dose?” — Lynne from Texas

You hit on the key point here. There does appear to be slightly improved effectiveness with a longer period of time between the first and second dose, and some parents may choose to wait eight weeks instead of four weeks. But this has to be balanced with the risk of infection during that period, as one dose does not provide much protection.

For my kids, I am choosing not to delay that second dose for this reason, but I can certainly understand if other parents decide differently.

Can I “mix and match” vaccines?

In March 2021, I got the J&J vaccine. Over time, I learned about its inferiority to the mRNA vaccine. So, I decided on my own to take a second dose of the Pfizer vaccine, even though this wasn’t recommended at the time. Is this effective? Should I get a second mRNA dose? I am 68 years old and feel very nervous. — Ilir from Massachusetts

The CDC has new data that address the exact question you are referencing.

According to a report just released yesterday, a single shot of the Johnson & Johnson vaccine offers only 31 percent effectiveness in protecting against hospitalization. Two shots of J&J increased it to 67 percent. For people who received J&J and then an mRNA vaccine (like you and me), the effectiveness increased to 78 percent. This is very good, though still slightly less than the 83 percent effectiveness from three mRNA shots.

The CDC is therefore recommending that all adults 18 and over who got only the single J&J shot to receive a second vaccine. They are also allowing people in your and my situation to receive a second booster vaccine of either Pfizer or Moderna, if it’s been over 4 months since our last shot.

Given your age and concern you’re expressing about covid-19, I would advise that you receive this second booster of mRNA now.

Are large gatherings safe right now?

“My fiance and I are getting married in Virginia Beach in September, and we are struggling with what to ask of our guests when it comes to coronavirus vaccinations and testing. Is immunity from vaccines even strong enough at this point to ask vaccination of our guests? What types of testing and time period for testing would you recommend we request? I am especially concerned about my fiance’s 95-year-old grandmother and our other grandparents who are older and/or have health conditions that put them at higher risk.” — Sara from New York

Those who are up to date with their vaccines and boosters are less likely to be infected compared with those who are unvaccinated. People with recent infections (in the past three months) are also less likely to be infected. I think it’s reasonable to require vaccination and up-to-date boosters or proof of recent infection.

Testing is another layer of protection that could further reduce risk. The key is to require same-day testing — ideally testing that’s done at the wedding site. The closer the time of the test to the gathering, the better, as rapid testing is a snapshot in time. It is pretty good at detecting whether someone has enough viral load at the time of the test to be contagious to others.

Also, make sure to advise guests on covid-19 protocols in settings associated with the wedding. For example, if people are also going to crowded bars and restaurants, they could become infected at these settings and not at the wedding itself. Those at higher risk for severe illness, such as your fiance’s grandmother and your grandparents, should be advised to avoid these higher-risk informal gatherings for their own protection.

September is still several months away. I’d monitor closely for coronavirus transmission levels leading up to your wedding. If transmission levels are high, the grandparents and others with more susceptibility to severe illness might wish to take additional precautions — for example, wearing N95 or equivalent masks while indoors and forgoing indoor meals with others.

Best wishes and congratulations in advance!

What about small gatherings?

“Given the rising covid numbers in New York, would you advise attending a small (six people) gathering in a house in two weeks? We are all vaccinated and double-boosted. I am not sure everyone will test beforehand, but if not, would you advise it?” — Adrienne from New York

I’d advise testing everyone if anyone in the group of six is concerned about contracting covid-19.

Remember the “two out of three” rule: Indoor events can be quite low-risk if you have two out of three layers of protection (vaccination, testing or masking). Having everyone vaccinated and boosted reduces risk. Requiring same-day, at-home tests further reduces risk. I think this is a common-sense, easy-to-implement measure that helps keep everyone safe and provides peace of mind to attendees, especially in areas with high covid-19 levels.

If I’m vaccinated, can I safely visit unvaccinated people?

“I’m a small town pastor in central Pennsylvania. Where I live, there is a pretty even divide between covid cautious people and the anti-vax/anti-mask folks. My church has been good about masking and distancing for worship. It’s gotten way past time that I visit some who cannot attend. Can you suggest how to handle personal protocols for these visits? I am fully vaccinated and boosted; my concern is for others in the community and the person I am visiting. Right now, I am masking during these visits, testing before leaving and spacing them to only one a week. Where I can, I try not to do any chores in the three days before an unvaccinated (or unknown) parishioner. Is this good enough? Not visiting, I think, hurts more than the risk of visiting, especially the isolated, homebound folks.” — Julie from Pennsylvania

Thank you for your work and your ministry. No doubt, your visits will bring much joy and connection.

It sounds like you are concerned about two things: the risk you could pose to the people you are visiting, and the risk that you’d contract covid-19 during the visits and spread it to others in the community. Since you are vaccinated and boosted, if you wear a high-quality mask (N95, KN95 or KF94) during your entire visit, the risk of either is extremely low.

Indeed, this is what health-care providers have been doing, even with patients we know to be actively infectious with covid-19. If you are masked the entire time, you are extremely unlikely to spread or contract the coronavirus. You do not need to quarantine in advance, test after or limit your visits.

“My daughter will be getting married in April this year after several postponements due to the pandemic. It is a destination wedding in a county in North Carolina that is currently ranked as medium risk. The hairdresser and makeup artist have both advised that they are unvaccinated but have committed to getting tested prior to the appointment date, as well as wearing a proper (KN95) mask and face shield while performing their tasks, both of which will require them to be within inches of her head and face for about two hours. They will also be performing the same hairdressing and makeup applications on other bridesmaids. Is it too risky to be within such close proximity for that long period of time? I’m very concerned about my daughter’s safety and also feel responsible for the safety of others participating. As the host of the wedding, I don’t want it to be a super-spreader.” — Jan from Virginia

Congratulations to your daughter — and to you! I think testing and masking will be sufficient to limit the risk of covid-19 to your daughter and the other bridesmaids. To ensure that the tests are as reflective of infection status as possible, you could ask that the hairdresser and makeup artist take them that morning, and then have a backup plan if they end up testing positive.

What protections should we take when traveling?

“I understand airplane ventilation is excellent — but is it a match for all these unmasked covid-positive travelers now?” — Ali

The CDC still recommends masking on flights. People who are concerned about contracting covid-19 should keep masking. I’d urge that they mask especially during the highest risk parts of the plane ride — specifically boarding and deplaning — when air is not being circulated. And if you mask, make sure it’s an N95, KN95 or KF94!

“I have a dear friend who is flying up for a visit. She is vaccinated and boosted, as am I. However, she has frequent contact with a relative who is unvaccinated. Besides possible personal risk, I feel protective toward other seniors (all vaccinated and boosted) we plan to see during her visit. I don’t want to offend my friend, but between exposure from the flight and the unvaccinated friend, should I ask her to take a coronavirus test when she arrives? Would it seem more polite if I suggested we both take a test? Also, would it be reasonable to ask if she would avoid contact with the unvaccinated relative, for example, five days before she flies up?” — Christina from Washington

It’s entirely reasonable for you to ask your friend to test when she arrives and to reduce her risk exposure before her visit. The flight itself can be very safe if she wears a high-quality mask the entire time. I’d be more concerned about her other exposures before the trip. In addition to seeing her unvaccinated relative, is she going to indoor restaurants?

Consider asking her to reduce her exposures for three to five days before her trip, which includes not getting together with her unvaccinated relative. Then offer her a rapid test upon arrival. As you said, you could take a test, too. Frankly, I think this kind of rapid testing should become the norm for people who do not want to get covid-19. By testing yourself before seeing others, you are making sure you aren’t going to inadvertently infect your friends — which I’m sure no one wants to do.

“I will travel by air to Michigan in April. I am immunocompromised, but vaccinated and boosted; the family I will live with for a week is unvaccinated but test regularly. Should I wear a mask at all times inside the home and in the car during my trip?” — Patricia from California

Are the people you are visiting willing to reduce their risk while you are visiting them? Specifically, starting at least three days before your visit and for the week that you will be there, can they wear high-quality (N95, KN95 or KF94) masks while in any indoor public spaces, refrain from indoor restaurants and not gather indoors with non-household members? If so, then they could all test the day you arrive. If they are negative and continue taking precautions, then you do not need to mask while with them.

“We have been planning a trip to Disney World that’s been canceled four times during the past two years. There are two families with children aged 3 through 7, my two daughters and their husbands, and me (I’m 66 and in good health). The children over 5 are vaccinated; the 3-year-old and 4-year-old are not. Two of the adults and the 4-year-old recently had covid-19. We plan on wearing KN95 masks when in large crowds and indoors. We also plan on dining outdoors or if we need to eat indoors, to go during off-hours to be away from other diners. Do you think this is still too risky? We really want to bring the children while they are young. They have missed so much.” — Linda from New York

You should take this trip. The adults are vaccinated, and especially if they are boosted, the risk of severe illness to them is low. The children over 5 and the 4-year-old who recently recovered from covid-19 are also at very low risk for severe illness.

The person you probably want to protect the most is the unvaccinated 3-year-old who has not had the coronavirus. Many families of young children have already decided that the likelihood of severe illness for their unvaccinated kids is low enough that it’s worth resuming all pre-pandemic activities, without restrictions. You want to be cautious, which I understand and respect. I believe that the precautions you are taking will further reduce your family’s risk of contracting covid-19 while still allowing you to enjoy a great vacation to Disney World.

“I have an unvaccinated toddler (1½ years old), and we are having family visit from Europe. They are vaccinated and will be tested before travel, but I am wondering what the best protocol is for testing after arrival. They will be staying with us. Both my husband and I are vaccinated and boosted, but my concern is with our child.” — Gina from Los Angeles

Ask your visiting family to take a rapid test as they arrive at your house. If it’s negative, and they had another negative test just before traveling, chances are that they do not carry the coronavirus. For an additional level of protection, ask the visitors to reduce their risk and do not dine indoors for three days before their travel. They should also wear an N95 mask or equivalent during the flight. I hope you all have a terrific reunion!

“My son (18) tested positive for Covid on Monday. His symptoms started last Sunday. He is schedule to travel to Europe next Wednesday. Should he wait to test negative before he travels? Is 5 days of isolation the rule as long as he is asymptomatic?”— Ana

By my count, your son will be traveling more than 10 days after when his symptoms first started, which is when the CDC says he can travel (assuming his symptoms are resolving and he doesn’t have a fever). I would add that he should do a rapid home antigen test. If he tests negative, he can definitely travel.

What precautions should I take when welcoming houseguests?

“We will be having houseguests in June who will have been traveling throughout the West for several months. The two middle-schoolers have had vaccinations, and both parents have been vaccinated and were boosted once in November. Before joining our household, we will have everyone tested, but what do we do throughout their week-long stay? They will be using our house as a base for day trips without us to museums, ballparks, restaurants, etc., throughout their stay. We will ask them to mask in indoor public spaces, but should we also ask them to take repeated tests? (Four tests a day for seven days is a lot of tests!)” — Janet from California

I have two questions for you: How important is it to you to keep avoiding the coronavirus, and how willing are your houseguests to restrict certain activities?

If it’s crucial to you to not contract the coronavirus — for example, if your family is extremely vulnerable to severe disease due to age and underlying medical conditions — then you should require additional precautions for your houseguests. They should wear N95 or equivalent masks in all indoor public settings. They should also avoid indoor dining and not get together indoors with others outside your two families.

If your visitors are willing to follow these precautions, then you could test once when they arrive and, if you wish to be extra cautious, once again midway through their stay.

“We will be spending about six weeks this summer in a shared house with younger relatives. We are in our seventies, in good health with no underlying conditions. At the same time, we continue to try to avoid covid by masking indoors, avoiding crowds, not eating inside restaurants and doing home tests before gathering with friends. The young people in the house want to go dancing in clubs, etc. We understand. Is there a way we can live together safely? If the more active people test every day, will that be sufficient?” — Avra from Washington, D.C.

This is really hard. I understand your desire to see your relatives and also to have them go about their lives. The problem is that their exposure puts you and other more cautious family members at risk.

Regular home antigen tests can definitely help in that they would detect if someone has a high enough level of virus — at the time of the test — that they could infect others. The shorter the interval between tests, the more likely it is that you will detect infection in time. If you have the resources to do daily tests, that could substantially reduce risk.

If you want to reduce infection risk further, perhaps you could also ask the younger relatives to take some precautions while with you. Could they consider forgoing crowded nightclubs in favor of more outdoor events? If they really want to engage in higher risk events, could they cluster them together on certain days, and then avoid common indoor space in your house for the few days after?

Is it safe to go to the gym unmasked?

“The Oregon indoor mask mandate expires March 12. So far, everyone at the gym has been wearing a mask, but they will stop wearing masks after the mandate ends. I plan to continue wearing an N95 at the gym and other indoor places like grocery stores. I will be traveling internationally so need to stay negative and provide a negative test result for travel. Is it safe for me to be at the gym with my N95 but no one else is masked?” — Patty from Oregon

Yes, an N95 at the gym should be sufficient, because the N95 is highly protective for the person wearing the mask.

To parse this a bit more, you are raising two related but different concerns. First is that you want to be safe at the gym. Second is that you want to continue testing negative.

If you are vaccinated and boosted and in generally good health, I think it would be reasonable to go the gym unmasked, knowing that the risk of severe illness to you is very low even if you were to contract covid-19. But, right now, you have another aim: You don’t want to get the coronavirus at all because it could impact your travel. If that’s the case, wearing an N95 (or equivalent) when in crowded indoor settings is important, not because it isn’t safe to go without one, but because it will prevent you from contracting and then testing positive for the virus.

Will omicron lead to herd immunity?

“Can you look into your crystal ball and tell us whether you think this rapid omicron surge will lead to herd immunity?” — Rachel

Don’t I wish for a crystal ball! Of course, I don’t have one, but I have hope. My hope is that omicron will convey some level of immunity to a large proportion of the population and that, combined with vaccination, we will come close to or reach herd immunity. Perhaps we will have a fairly quiet spring and summer, and then covid-19 can become just another seasonal virus like influenza. However, I don’t know that this optimistic scenario will occur. This virus has thrown us many curveballs, and it may throw many more, by way of new variants that arise, for example.

Does contracting omicron provide added covid-19 immunity?

“My 11-month-old contracted covid-19 from day care last week. My husband and I (both vaccinated and boosted) tested positive as well. We have delayed many things, both big — baptism, a cross-country flight to introduce her to my grandparents, swimming lessons — and small — haircuts, visiting restaurants — in an effort to shield her from covid. Now that we’ve all had it, do you think it’s safe to do these things after we recover? Should we wait until she can be vaccinated as well?” — Bethany from Illinois

My husband and I have put off many big and small activities for the exact same reason your family did. If our kids were to contract the coronavirus, we would resume most of these activities. That’s because there will be some degree of immunity after infection. It’s likely not that durable and might not last beyond a few months, but it will almost certainly protect against severe illness, which is our main concern.

This is not a reason to try to get covid-19, but families that have recovered from it should be able to experience a short respite. I’m not advising that you throw all caution to the wind, but rather that you decide which activities you’ve really missed and go about doing them, now that your 11-month-old has at least some short-term immunity.

What is the likelihood of contracting the coronavirus if I’m vaccinated?

“My son, who doesn’t believe in the vaccine, asked why should I be concerned about being around unvaccinated people in a room if I’m vaccinated. ‘Vaccinated people can have the virus just as an unvaccinated person, and you can still get it, Mom, whether I’m vaccinated or not.’ How should I answer this?” — Karen from California

According to the CDC, vaccinated people are five times less likely to be infected by covid-19 compared with the unvaccinated. So yes, someone who is vaccinated could still have the coronavirus and be able to spread it, but they are five times less likely to be infected in the first place than an individual who’s unvaccinated. That’s why, if given a choice to be in the same room for prolonged periods with an unvaccinated or a vaccinated person, I would choose the vaccinated person every time.

What additional precautions should immunocompromised people take?

“I have stage four cancer and am currently on chemo. Though fully boosted, I’m still concerned when I go shopping, etc. How cautious should I be?”

I think you should be very careful, because you are in the category of people who are immunocompromised and more vulnerable to severe outcomes from covid-19. I would highly recommend that you wear an N95 or equivalent when in public places (like grocery stores and other shops). Ask that all those you gather with test just before seeing you. And speak with your doctor to see if you qualify for Evusheld, the preventive antibody that further reduces risk for people with immunocompromise.

“What is the ‘living with endemic covid’ going to look like for the immunocompromised? Are they going to have to continue living in masked and isolated limbo indefinitely?” — Benjamin from Oregon

Short-term, those at high risk for severe illness should continue to hunker down during the omicron surge. They should be associating only with others who are vaccinated and boosted, and even those close contacts should be tested before gathering indoors. It’s essential to wear an N95, KN95 or KF94 mask in any public indoor spaces, and exposure to those settings should be limited as much as possible.

My hope is that things will change this spring when three things happen. First, there will be a lot more testing. Readily available, reliable and cheap (or better yet, free) home testing will make it easier for people to test before seeing one another. It should become the norm for grandchildren to test before visiting an at-risk grandparent, for example.

Second, on-demand treatment that renders covid-19 less deadly will become available. Such treatments already exist. Pfizer’s antiviral pill, Paxlovid, cuts hospitalization or death by nearly 90 percent. The supply is very limited, but the Biden administration has announced that it is purchasing 20 million treatment courses. We need enough so that all at-risk individuals can quickly access these pills should they test positive.

Third, immunocompromised people will be able to receive antibodies that protect them against covid-19. The Food and Drug Administration has approved Evusheld, a direct antibody infusion that is protective for about six months. People who don’t produce enough antibodies on their own should receive this injection, perhaps in combination with additional booster doses, to increase their immune protection.

Testing, treatments and preventive antibodies are all in short supply at the moment. My hope is that by the spring, or summer at the latest, there will be enough of all three so that those at high risk from covid-19 can resume more pre-pandemic activities with better protection against the virus and treatments should they become infected.

“I’m immune compromised with a kidney transplant. Am I virtually 100 percent protected double-masking including a tightly fitted N95 mask.” — Anonymous

You are in the category of individuals who are at the highest risk for covid-19. In general, people are very well-protected with a tightly fitted N95 mask, but my concern is for other settings you might be in where you won’t be wearing a mask — for example, dining with friends and relatives. If you will be maskless in these settings, it’s essential that others around you are also vaccinated and boosted, and I’d strongly urge that they all obtain rapid tests before seeing you. In areas of high community transmission, I’d advise people in your situation — individuals with severe immunocompromise — to hunker down and use every precaution.

“I am immunocompromised, vaccinated and boosted. My son-in-law is against vaccination and will not allow my grandchildren to be vaccinated (my daughter is vaccinated). How can I safely see my grandchildren again? I see them outdoors, masked, but I want to hug them and kiss them and have them spend the night with me and read them bedtime stories again. I miss them so much my heart aches, and they miss me, too. Both grandchildren want to be vaccinated, but this is not an option and I don’t believe it ever will be. I am desperate to be with my grandchildren again. Is there any way I can see them safely besides outdoors?” — Kristina from Missouri

Kristina, my heart aches for you. This is such a difficult situation for your family.

You say your son-in-law will not relent on the vaccination front, but will he agree to other types of precautions? For example, could his household quarantine for three days, then have the grandkids be tested just before they come to see you? If you trust that your daughter’s family truly will quarantine and you can administer a rapid test to the kids immediately before your visit (and, to be even safer, every day of your being together), then they can see you without restriction, at low risk to you.

“I need to get some urgent dental work completed. I’ve been vaccinated and boosted, but I am immunocompromised and have some other preexisting conditions. I live in a state where covid-19 counts have decreased by a large percentage, but, of course, there are still new cases. Do you have any suggestions as to how to make dental work as safe as possible?” — Ruth from New Jersey

I’d definitely advise that you get your urgent dental work done. Many people have put health maintenance on hold during the pandemic, delaying cancer screenings, blood pressure and diabetes checks and other essential appointments. As coronavirus cases finally decline, this is a good time to get caught up.

Dental work is different from most other indoor activities in that you cannot be masked during the procedures. But there are ways to reduce risk. Ask your dental practice what protocols they have in place. At a minimum, they should require all staff to wear high-quality masks when interacting with patients. Many places also require staff vaccinations, which would reduce their chance of contracting the coronavirus and therefore spreading it to you. Others have improved ventilation or have guidelines on physically distancing patients.

Convey your specific concerns to your dental office. Can the office make special arrangements for you? For example, could you be the first patient in the morning and be situated in the most isolated space possible? Could the office ensure that the staff members treating you are vaccinated, even if not everyone in the office is? All these steps can reduce covid-19 risk to you while keeping up your dental health.

“I’m immunocompromised due to medications for my rheumatoid arthritis and have had four doses of Moderna. I still plan to mask indoors in stores and avoid restaurants. How risky is it for me to be with my grandchildren who are in day care? They are not vaccinated yet. Their parents are all vaccinated and boosted.” — Elizabeth from Virginia

Is it practical for your grandchildren to be tested before seeing you? If so, that substantially reduces their risk to you.

If not, consider your grandchildren’s exposures. Are they of the age that they can reliably wear masks during day care? Do their parents limit their risk in other ways by, for example, not having indoor, maskless playdates and avoiding indoor restaurants? Without testing, visiting with them outdoors is still the safest option, but you might also decide that because the grandkids are taking additional precautions, you could see them indoors, too.

One additional consideration is the availability of antiviral treatments. If you have easy access to molnupiravir or paxlovid (the two pills authorized thus far to treat covid-19) or to monoclonal antibodies, that could also change your risk calculus. These treatments substantially reduce your risk of severe disease if you were to contract covid-19.

“I am in very good health and have no covid-19 risk factors other than being over 70. However, my husband has multiple health risk factors. Should I continue to mask in any situation where he would?” – Lynn from Indiana

Yes. In deciding what protective measures to keep, you should consider the risk of all members of your household. If one person still needs to mask in certain settings because they are susceptible to severe illness, everyone else should mask in those same settings, too. In your case, you would want to prevent contracting covid-19 yourself so that you don’t pass it on to your medically vulnerable husband, and I’d encourage you to mask in all situations that your husband does.

“I am an overweight 73-year-old woman with diabetes and mild asthma. I’ve been a prisoner in my home since the pandemic started trying to not get covid-19. I am fully vaccinated with two boosters and always mask. What should be my limitations now? I sure would like to shop a little again and see my son in Virginia.” — Trudy from Florida

Trudy, you should be able to do these things. You are well protected from severe illness because of your vaccination and boosters. I understand your desire to not get covid, as well as your desire to resume social activities that are meaningful to you.

You can go to the shops. Make sure you wear a well-fitting N95, KN95 or KF94 mask and keep it on the entire time you are in an indoor public space. If you are not used to wearing these masks, test them out at home and be sure there is a good seal around your face. Start with a short trip and then increase the length over time. Consider going to shops that aren’t so crowded. If people start packing in too close for your comfort, leave and come back.

I also understand the desire to visit your son. My concern for your covid-19 risk is not so much the trip itself (you can wear an N95 or equivalent during travel) but what happens once you are there. Does your son also take precautions? If not, can he be cautious for a few days before you arrive, then test before seeing you? Make sure to stay out of indoor restaurants and other crowded indoor settings while you are visiting him.

Your situation underscores the need for all of us to consider that good health is about both our physical and mental well-being, and that it needs to be considered in a holistic way. Trying to avoid covid-19 is a good goal, as is resuming activities that improve overall well-being.

What additional precautions should the elderly take?

“Can healthy, fully boosted 76-year-olds go to the gym masked, travel or see other boosted friends indoors for meals in homes? Why are all elders in one category?” — Anonymous

Since last April, when vaccines became widely available, I’ve been writing about how vaccinated people need to be able to make their own decisions based on individual medical circumstances, risk tolerance and values. Many vaccinated people remain “vaccinated and cautious” and are hesitant to resume pre-pandemic activities. Others are “vaccinated and done,” and accept that there is a risk of infection but are eager to travel, see friends and go back to doing things they’ve really missed. These are all reasonable decisions — despite omicron, and no matter your age!

“My son and daughter-in-law want to visit us this summer from California. Both my husband and I are in our mid-70s, vaccinated and boosted, and in good health, as is my son. My daughter-in-law is unvaccinated and part of the ‘California wellness group.’ We would love to see them but are concerned about risks. What is your medical and ‘kindly human’ opinion on how to handle this?” — Susan from New Jersey

I can certainly understand the desire to see your family and also your wish to do so as safely as possible.

Is your daughter-in-law willing to take a test before seeing you? Even better is if she and her family can reduce their risk exposure for three days prior to their flight and then take a rapid test before being with you and your husband. If they do this, their risk to you will be very low, and you can host them in your home and socialize with them indoors without the need for masks.

“I am 68 and live with my 98-year-old mother. I would like to go to New York City to visit my two adult children. I am concerned about being around my daughters. They both use the subway, dine inside restaurants, go to bars, etc. Do they need to curtail these activities prior to my arrival to make it safer for me and for my mother when I return home? My mother and I are both double-boosted. (The last booster was a month ago.) My daughters are vaccinated, and one has a single booster.” — Lynne from Wisconsin

Here’s my question: How important is it for you to avoid covid-19 yourself? I certainly understand that you do not wish to contract the coronavirus and spread it to your mother, but is it also very important for you to avoid the coronavirus?

If so, then you should ask your daughters to stop high-risk activities such as indoor dining and going to crowded bars for at least three days before your visit. They can go to work and ride the subway; just make sure they wear an N95 mask or equivalent (KN95, KF94) the entire time when around others. They should both take a rapid test just before you visit, and then stay out of these high-risk settings while you are there. Your daughter who has not yet had her booster should ideally get the booster in advance of your visit.

If you are not concerned about your own risk but worry primarily about your mother, there is another path, too: have your daughters carry on with their own activities and then, when you arrive home, you quarantine for at least three days and then get tested before seeing your mother.

Whichever path you choose, I hope you have a terrific visit with your daughters!

Can people with covid visit each other?

“Can someone with covid-19 visit someone else in another household with covid? Both parties have been fully vaccinated. One tested positive within the past five days and the other within the past 10 days, and both have resolving symptoms on Paxlovid.”  David from Tennessee

In general, people who have covid-19 can be in isolation with one another. It’s unlikely they will somehow infect one another. Many isolation facilities are designed with this in mind. I think the scenario you are laying out is fine. The key is to stay separated from those in your respective households who are not infected with the coronavirus.

Is it safe to go to restaurants?

“I’m a clinically obese 62-year-old woman with a mild heart condition and controlled high blood pressure. Will I and other seniors, most of whom have some underlying condition, ever be able to eat in restaurants again?”  Caroline from Minnesota

At this stage of the covid pandemic, many older individuals have resumed dining in indoor restaurants. Whether you do depends on several factors.

First, what is your risk of severe outcomes from covid-19? If you are vaccinated and double-boosted, your chances of hospitalization and death are much decreased. Obesity is a risk factor, but I would ask your doctor about what your other risks actually are. A mild heart condition and controlled hypertension might not substantially increase your risk.

Second, what is the level of coronavirus transmission in your community? The lower the level, the less likely you are to encounter the virus. The Centers for Disease Control and Prevention has a helpful county-by-county map that can help you assess your local conditions.

Third, what are conditions in the restaurant? A restaurant that has well-spaced tables and good air circulation is going be less risky than one where you are virtually shoulder to shoulder with other patrons.

Finally, how much does indoor restaurant dining mean to you? Enjoyment of life is an important part of overall health. If going out to eat means a great deal to you, factor that into your decision. If you do decide to restart dining indoors, consider doing so when the transmission level in your area is low. Choose a restaurant with good distancing and ventilation, and go with friends who are similarly cautious.

Is it safe to swim outdoors?

“Is it safe to swim laps in an outdoor pool where there are swimmers in adjacent lanes? What if you are alone in the pool but other swimmers have been in it before you? Does the virus live in water, and can you catch it by swimming in it, or does the chlorine in the pool kill it?” — Holly from Georgia

Swimming outdoors is very safe. The coronavirus is a respiratory pathogen transmitted through the air or direct contact. It is not transmitted through large bodies of water such as pools. If you were swimming indoors, there would be a higher risk of transmission — not from the pool but from people packed close to you. Outdoor swimming, or swimming indoors in a well-ventilated area where swimmers are distanced, is extremely low-risk. Enjoy!

Is it safe to resume use of reusable bags?

“At the beginning of the pandemic, we stopped bringing our reusable bags to the grocery store. Given what we have learned about transmission of coronavirus, is it safe to resume use of reusable bags instead of disposal plastic bags provided by the store?” — Maggie from Washington

Yes. Not only is using your own bags just as safe as using disposable bags, it’s better for the environment. Make sure when you come home and finish unpacking all your groceries, you wash your hands well with soap and water. And make sure you are wearing a high-quality mask at the grocery store. That’s the most important step to preventing transmission.

Is it safe to resume carpooling?

“Since the pandemic began, my wife and I have driven a car only with each other. Many of our friends have returned to the practice of carpooling to events and activities. We are in our early 60s, fully vaccinated and boosted, and generally in good health. What are best practices around carpooling?” — Don from North Carolina

Let me ask a question back to you: What activities have you already resumed? For example, if you are already getting together with your friends anyway, indoors and without masks, then there’s not much additional risk to carpooling with them to the same destination.

On the other hand, if you are still socializing outdoors only, or requiring tests before unmasking indoors, then you might consider taking additional precautions when in the car with others. The safest thing to do is for everyone to wear an N95 or equivalent (KN95, KF94) mask. Rolling down the windows to improve ventilation can help, too.

Is it safe to resume playing sports?

“I have two sons who love to play basketball. (They are both very good, by the way!) One is 35 and plays in an adult league indoors. He has a 3-month-old baby at home. The other is a college senior and plays outdoors with other students at the school. I am in health care, so I’m cautious about wearing a mask indoors and taking other precautions. I told my older son he should not be playing in the league for a while. I think the younger one should be okay since he’s outdoors. What would be your advice?” — Gregory from California

The outdoor league for your younger son is definitely safe. Indoor basketball is, of course, higher-risk than outdoors. How risky depends on the setting. Is it a well-ventilated gym with a lot of space? Are the other players vaccinated and boosted? What is the level of coronavirus transmission in the community?

Newborns have limited immunity, and many new parents want to reduce risk as much as possible. Still, the physical exercise and camaraderie from basketball might be crucial for your older son’s well-being, and perhaps he is reducing risk in other ways (for example, just playing basketball but not using the locker rooms and not getting together for indoor meals with his teammates).

I think having a conversation with your older son could help you express your concerns but could also help you understand how risky the situation actually is — and how valuable continuing basketball is to him.

Is it safe to go on a cruise?

“What is your opinion on cruising at this time?”

Cruising is an activity — like all in-person other activities — that has risk. Cruise operators can reduce risk by requiring rounds of testing and vaccination (and boosters). The risk of cruises has to be balanced with the benefit. Many people love cruises and think it’s an essential part of their travel experience. If that’s you, it might be worth the tradeoff on risk.

If you go, be prepared to test positive. Have a plan for what happens if you contract covid-19 while on board. Will you be able to access paxlovid or other treatments? What will isolation be like? Knowing what happens if you test positive will also help in your decision-making.

Are more shutdowns possible?

“Do you think another shutdown could be possible in the near future?” — Valerie

I very much doubt that there will be shutdowns on the horizon for covid-19. There is very little public tolerance for shutdowns and the resulting harms they bring. These types of blanket restrictions are also not necessary at this point in the pandemic, when we have many more tools that help us to mitigate the worst effects (vaccines, treatments, tests, masks, etc). That said, covid-19 is unlikely to be the last threat we will face, and we should be prepared for emerging viruses in the future.

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