As I write this, we are told that more than 7.6 million Americans have caught the coronavirus. Case reports are climbing again. According to the Wall Street Journal (Oct. 8, 2020), “New U.S. Coronavirus Cases Top 50,000 for the First Time in Five Days.” Over 212,000 people have died. Globally, cases exceed 36 million and more than 1 million people have died. There is talk of another wave this winter. It may have already begun. Cases continue to climb in states in the upper mid-west. Some areas that seemed to have the virus under control, like Massachusetts and New York, are now experiencing increases. Is there any way to avoid COVID-19 as the pandemic continues?

CLUE: Avoid Clusters!

The Atlantic Offers Insights!

We have read a tremendous number of articles about the coronavirus and how it spreads. To date, though, nothing compares to this piece in The Atlantic (Sept. 30, 2020). It reveals why clusters are so critical to the spread of COVID-19. The title is: 

This Overlooked Variable Is the Key to the Pandemic
It’s not R.”

First, a warning. The article is long and detailed. It is written by Dr. Zeynep Tufekci, an associate professor at the University of North Carolina at Chapel Hill. She is brilliant and her detailed analysis does not cut corners. Dr. Tufekci is a big data researcher. That is why her analysis is so compelling.

NPR Offers the CliffsNotes on Clusters!

If you do not have the time or the energy to read her Atlantic article, you can listen to Dr. Tufekci’s 6-minute interview with Lulu Garcia-Navarro on NPR at this link. She suggests that clusters are a key to understanding what has happened. She also teaches us how to avoid COVID-19.

Some Clues to Avoid COVID-19:

Six feet of distance between people is no longer adequate! The CDC just revised its guidance on aerosol transmission of SARS-CoV-2. We wrote about the CDC’s flip-flop-flip-FLOP at this link.  

Two weeks ago, the CDC reversed a previous statement about aerosol transmission, implying that it was premature. Now, there is an acknowledgement that tiny viral particles can float in the air beyond six feet and linger aloft for hours (CDC Guidance, Oct. 5, 2020).

The CDC still maintains that the primary means of transmission is between people who are within six feet of each other. We are not convinced that these public health authorities have a lot of science to back up this contention, though.

What we do know is that the dispersion of SARS-CoV-2 in a confined area is critical to catching COVID-19. That’s why enclosed spaces and rooms with inadequate ventilation are really risky. Air handling also becomes a critical variable. We have written about the dangers of sitting in the path of an air conditioning unit if the person “upwind” is exhaling viral particles at this link

Can You Catch COVID-19 From >10 Feet Away?
Some states are reopening restaurants, beauty shops and gyms. Can patrons still catch Covid-19 if they stay 6 feet apart? 10 feet may not be far enough!

Unwitting “Studies”

More recently we described an accidental “experiment” at a Dutch nursing home. One building had an energy-efficient ventilating system that did not bring in fresh outside air unless carbon dioxide levels reached a certain threshold. Over half the healthcare staff in this building came down with COVID-19 and 81% of the residents caught the virus. Other buildings on the campus had old-fashioned fresh-air circulation. None of the residents or staff in those facilities caught the virus.

We also describe how a bus ride could pose risks. That’s because air circulation is not great unless the windows are open. You can read more about ventilation at this link

You CAN Contract COVID-19 by Breathing Viral Particles
The ongoing debate about aerosol transmission of the coronavirus should stop! People DO contract COVID-19 just by breathing. Here are data!

Other Ways to Avoid COVID-19:

The CDC recommendations are not very exciting. They call for social distancing, mask wearing, washing hands and avoiding crowded indoor spaces. (CDC Guidance, Oct. 5, 2020)

The Three Vs:

We find Dr. Tufekci’s three Vs especially helpful:

  • Venue
  • Ventilation
  • Vocalization

The bottom line is that you should pick your places carefully. Outdoors good! Indoors bad, unless you know that there is great ventilation. And do not go where there is a lot of loud chit-chat! Stay away from loud talkers. Remember the phrase, say it, don’t spray it! And we hate to say this, avoid laughers. Ditto, angry people. Heck, you don’t want to hang around people who are mad anyway. 

Dr. Tufekci cautions us to avoid the three wrongs:

You want to avoid the:

  • Wrong Person
  • Wrong Place
  • Wrong Time

Some people are super emitters. They are trouble a day or two before they even have symptoms. By the way, that could also be you! You will never know if someone is sick just by looking at him. And you will never know that you are at a super spreader event because someone near you is especially dangerous–at least, not until after the fact, when it will be too late.

Quick Overview of The Atlantic Article:

We cannot do the article justice in a short summary, but here is our overall interpretation.

First, the spread of the coronavirus has not been even. Dr. Tufekci points out that northern Italy was hit really hard while other parts of Italy did much better. Brazil was hammered, but is on the downward slope. Spain, Germany, England and Israel had initial surges, flattened their curves and are now experiencing surges again. The Netherlands is in a similar nasty situation.

Then there are South Korea, Japan and New Zealand. These countries are doing surprisingly well. Why? That is, in part, what Professor Tufekci set out to uncover in her Atlantic article. She mentions all the usual suspects for substantial variations in COVID cases:


Herd immunity (especially in Sweden)
Prior immunity due to some viral exposure
Vitamin D levels
Preponderance of older people

The Real Culprits: CLUSTERS!

In the city of Daegu, South Korea, one woman was responsible for 5,000 cases of COVID-19. She was a super spreader. This is a prime example of a gigantic cluster effect. We have seen a much smaller example in the recent White House cluster.

Overdispersion and Super-Spreading:

A key point that Dr. Tufekci makes in her Atlantic piece is that small numbers of people may be responsible for tremendous spread of this disease:

“There are COVID-19 incidents in which a single person likely infected 80 percent or more of the people in the room in just a few hours. But, at other times, COVID-19 can be surprisingly much less contagious. Overdispersion and super-spreading of this virus are found in research across the globe. A growing number of studies estimate that a majority of infected people may not infect a single other person.  A recent paper found that in Hong Kong, which had extensive testing and contact tracing, about 19 percent of cases were responsible for 80 percent of transmission, while 69 percent of cases did not infect another person. This finding is not rare: Multiple studies from the beginning have suggested that as few as 10 to 20 percent of infected people may be responsible for as much as 80 to 90 percent of transmission, and that many people barely transmit it.”

Herd Immunity?

I know that a lot of people are pointing to Sweden as the model for solving the pandemic. Please read Dr. Tufekci’s thoughtful discussion of Sweden to get a more nuanced perspective.

She points out that “Sweden imposed a 50-person limit on indoor gatherings in March.” Schools were kept open, but only for younger children who were less likely to catch or spread the disease. And Sweden encouraged social distancing. People in Sweden tend to follow such advice.

Japan is another great example. It did not lock down its population. But the public health authorities recognized the risk of clusters.

Dr. Tufekci describes a:

“…strategy focusing mostly on cluster-busting, which tries to prevent one cluster from igniting another…Japan thus carried out a cluster-busting approach including undertaking aggressive backward tracing to uncover clusters. Japan also focused on ventilation, counseling its population to avoid places where the three C’s come together—crowds in closed spaces in close contact, especially if there’s talking or singing—bringing together the science of overdispersion with the recognition of airborne aerosol transmission, as well as presymptomatic and asymptomatic transmission.”

How to Avoid COVID-19!

So here’s the rub. There is no way to determine who is a super spreader and who isn’t. We still do not know who it was at the White House who infected so many people during the September 26 Rose Garden super spreader event.

It makes sense to me that we should try to “backward trace” to identify the key player in any outbreak. Call that person patient zero if you like. Once you can identify the person who may have triggered a super spreader event, you can move forward more efficiently with contact tracing.

Identifying a super spreader who does not have any symptoms is always challenging. Even when testing is rigorous, it is not possible to identify who will spread the virus and who won’t. Since we can’t tell who is a super emitter, our best strategy to avoid COVID-19 is to 1) stay away from risky venues and 2) steer clear of activities that increase your risks. What does that mean?

Have you ever heard the expression “can’t see the forest for the trees”?

I think the point is that a lot of people, including many public health experts, got caught up in the details of the coronavirus. They were focusing on things like ACE 2 receptors, hydroxychloroquine, genetic variations and health conditions that might make people more susceptible to COVID-19.

What they weren’t paying enough attention to were the situations that might make people especially vulnerable to catching the virus in the first place. And they weren’t working backward to identify patient zero, the individual who might have been a super spreader.

The People’s Pharmacy Tips to Avoid COVID-19:

In order to stay away from super spreaders and risky venues you need to:

1) Assume everyone you come in contact with could be a super spreader

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2) Stay away from anyone who speaks loudly, laughs, sings, sprays or is visibly angry
3) Avoid activities such as dancing or cheering where the people around you might be breathing hard or talking loudly
4) If you must go into a building, avoid enclosed spaces with poor ventilation and always wear a mask

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