Family Planning: Unmasked Offices

This post is several things.

First, it is the start of a regular feature of the newsletter, in which I will address a reader question in detail. I’ve done this before (check back for various posts entitled From the Mailbag), but I’ve rebranded here, with plans for doing this consistently. As with today’s, I’ll try to choose questions which echo a lot of what I’m hearing.

Second, it’s a little bit of a look back, since I’m going to talk through a COVID question below with an eye on the decision process I introduced more than a year ago now, in this Grandparents and Day Care post.

And, third, it’s a look forward. The decision process here shares a lot with the more general approach to non-COVID decision-making that I take in The Family Firm. This question feature will increasingly focus on non-COVID content (I hope…) as I ramp up to book release. If this approach resonates, I think the book will too. So please consider a preorder.

Now on to the show.

Dear Emily:

My office recently removed their mask mandate if you’re vaccinated. But, obviously, it’s on the honor system and I know there are unvaccinated people who aren’t masked. I’m in the office in an open room of cubicles all day. I’m fully vaccinated and so is my wife, but we have a 3 year old and a 10 week old at home.

I keep thinking about what if I bring the virus home, especially to the newborn. Should I be worried?

-Anonymous Reader

Reader:

Before getting into a decision process (and some data) here, I want to start by suggesting you reframe the last question. You asked “Should I be worried?” It’s a reasonable question, but ultimately an unproductive one. Choosing to be worried or not worried isn’t going to change anything. Let’s ask, instead: “Should I do something differently?” A question which implies a decision, which we can then turn to directly. And we’ll do so, with a slightly condensed form of my five-step decision process.

Frame the Question: Asking the question in the form “Should I do something differently?” is already helpful, but better still is to be able to articulate a small number of choices. I don’t know enough about your job to be sufficiently concrete here, but I can see a few things you might do differently, in ascending order of complexity.

Continue to wear a mask yourself & try to social distance at work
Petition your employer for mandatory vaccines and/or proof of vaccination for unmasking
Ask for a period of remote work, perhaps until your infant is older, vaccination rates increase further or cases fall more.
Continue to work in person but try to live separately from your family until your infant is older, vaccination rates increase further or cases fall more.

Depending on your job type and other aspects of your situation, the latter three may be infeasible, totally unappealing or in some other way impossible. But sitting down and thinking about the feasible options may help frame what question you want to answer in the data.

Evaluate Risk: It seems likely, regardless of how you see the options, that the key question here is what is the risk of transmission to an unvaccinated child as a result of your working in person around unvaccinated, unmasked people. A secondary question is on the magnitude of risk to your children if infected.

I’m going to focus in this answer on the first question, since I think it’s the one that is most uncertain to people now. There is much else written on the fact that risks to kids are low; for infants (under 3 months or so) we generally want to be more careful with all germs, but the COVID risks to them also seem low.

However: here I am going to really focus on the transmission question. Putting aside whether it would be very risky if one of the kids got COVID-19, how likely is that to happen?

The key to answering the transmission question is evaluating to what extent vaccines lower asymptomatic infection with COVID-19. We know from vaccine trials and population-level follow-ups that all the vaccines are very, very good — above 90% — at reducing serious infection with COVID-19. This includes reductions in hospitalizations and deaths. But the trials do not speak directly to asymptomatic infections because they didn’t track them.

However: as vaccines have become widespread, we’ve started to be able to learn about the extent to which the vaccines prevent against asymptomatic infection. The short answer is that infections are hugely reduced among asymptomatic people. I’ve taken the table below from the ever-helpful Monica Gandhi; original with links is here.

The reduction in asymptomatic infection is between 75% and 100%. To be clear what this means: if the risk of being getting infected in an interaction if unvaccinated is 1 in 10, the risk when vaccinated is something between 1 in 40 and zero. The largest studies put this at 90 to 95%, which would mean your risk of being infected would be between 1 in 100 and 1 in 200.

You can use this to think about your risk at work. That’s going to require a little bit of reflection on the number of people in your office, how many of them are vaccinated, how many are unvaccinated, mask wearing, and so on.

Example: Let’s say you work closely with 10 people, and in the new normal no one is masking, but you think only 8 of the 10 are vaccinated. The unvaccinated people are still at risk for COVID-19. What is the actual chance they are infected? It depends on the case rate where you are, although in most of the US it is probably well under 1%. Let’s say a risk of 1 in 200 for each of them, or about 0.5%.

You’re interacting with both of them in a sustained way, so let’s be conservative and say the baseline infection risk from each of them — if you were not vaccinated — would be 10%. This is comparable to in-household transmission and in an office setting your interactions are likely much less than at home. From the above we know this baseline risk is reduced a lot by vaccination. I’m going to assume it’s now 1 in 100.

So: your risk of getting asymptomatic infection from each unvaccinated person is their risk of infection (1 in 200) multiplied by the transmission risk (1 in 100) for a total risk of 1 in 20,000. Since there are two unvaccinated people, it’s 1 in 10,000. This is a very small number. If you had this interaction every day, you’d expect to be infected about once every 27 years.

There is then yet another adjustment for the risk of transmitting to your child — making this number go down further — and also an adjustment for the risk of serious illness — making the number smaller still. If you, yourself, continue to wear a mask you’d reduce the risk a bit more, although at this point all the numbers are very small.

Your precise situation may be different here. Maybe there are more people in the office, or a bigger share of them are unvaccinated, or the case rate is lower or higher. But I would venture that almost no matter how you slice it, the risks of bringing COVID home to your kids if you are fully vaccinated are really, really small.

The risks aren’t zero, and there is a level of risk we are going to need to live with. But we are seeing increasing evidence that vaccines protect the unvaccinated. Cases in the US among kids have fallen precipitously, even though they cannot yet be vaccinated. The same is true in Israel. A study just out from Finland shows household members vaccines protect unvaccinated household members (in that case, other adults).

Hopefully you can take some of these numbers and think about the magnitude of risk for going to work. And, armed with that…

Final Decision: The payoff to thinking carefully about your possible choices before going down this data hole is that it makes it easier to come to a final decision which is actionable. And once you decide on an action, you implement and move forward.

Ultimately, this decision is highly specific to your situation. I would imagine — given the low numbers I’ve put above — that for a lot of people the added risk from lack of masking at work is probably minimal enough that they would be comfortable just moving forward or, possibly, choosing to mask themselves. But this is ultimately an individual choice and it could look different in higher risk work situations (i.e. a meatpacking plant in a low vaccination rate area).

Once you make the decision, the best advice I can give is to make it final. Stop thinking about it! This ultimately harkens back to where I started: “Should I worry?” is a bad frame precisely because it doesn’t have an end. Decide if you should do something differently or not, what it should be and do it, or not. And then be done.