Tagged Hygiene and Cleanliness

C.D.C. Draws Up a Blueprint for Reopening Schools

C.D.C. Draws Up a Blueprint for Reopening Schools

Amid an acrid national controversy, the agency proposed detailed criteria for returning students to classrooms.

Students returning to P.S. 189 in Brooklyn in December, when New York City reopened its schools after rising infection rates had forced a closure.
Students returning to P.S. 189 in Brooklyn in December, when New York City reopened its schools after rising infection rates had forced a closure.Credit…Victor J. Blue for The New York Times
  • Feb. 12, 2021, 2:14 p.m. ET

The Centers for Disease Control and Prevention on Friday urged that K-12 schools be reopened and offered a comprehensive science-based plan for doing so speedily, an effort to resolve an urgent debate roiling in communities across the nation.

The new guidelines highlight the growing body of evidence that schools can openly safely if they put in effect layered mitigation measures. The agency said that even when students lived in communities with high transmission rates, elementary students could receive at least some in-person instruction safely.

And middle and high school students, the agency said, could attend school safely at most lower levels of community transmission — or even at higher levels, if schools put into effect weekly testing of staff and students to identify asymptomatic infections.

“CDC’s operational strategy is grounded in science and the best available evidence,” Dr. Rochelle Walensky, director of the C.D.C., said on Friday in a call with reporters.

The guidelines arrive in the middle of a debate that is already highly fraught. Some parents whose schools remain closed are becoming increasingly frustrated, and public school enrollment has declined in many districts across the country. Education and civil rights leaders are despairing about the harms being done to children who have not been in classrooms for nearly a year.

And teachers’ unions in some places are fighting against reopening schools before teachers can be fully vaccinated.

The Biden administration has made a high priority of returning children to classrooms, and the new recommendations try to carve a middle ground between school officials as well as some parents who are eager to see a resumption of in-person learning and powerful teachers’ unions resisting a return to school settings that they regard as unsafe amid the coronavirus pandemic.

Whether the guidelines will persuade powerful teachers’ unions — allies of Mr. Biden — to support teachers returning to classrooms remains to be seen. In advice that may be disappointing to some unions, the document states that, while teachers should be vaccinated as quickly as possible, teachers do not need to be vaccinated before schools can reopen.

The document embraces the often-repeated mantra that schools should be the last settings to close in a community and the first to reopen. But that has been followed nowhere in the country, and these guidelines have no power to force communities where transmission remains high to take steps, such as closing nonessential businesses, to decrease it.

As a result, some teachers’ unions will continue to argue that the overall environment remains unsafe to return to in-person classrooms.

A majority of districts in the country are offering at least some in-person learning, and about half of the nation’s students are learning in classrooms. But there are stark disparities in who has access to in-person instruction, with urban districts, which serve mostly poor, nonwhite children, more likely to be closed than nonurban ones.

Those are some of the places where education experts are most concerned about the consequences of students being out of school for such a prolonged period. There is growing evidence that some students who are learning remotely are falling significantly behind academically.

And, while data are still very limited, many doctors and mental health experts report seeing unusually high numbers of children and adolescents who are depressed, anxious or experiencing other mental health issues.

At the same time, many parents in urban districts, particularly poor and nonwhite parents, remain hesitant to send their children back to school even if given the option, out of fear that their children can get sick and possibly bring home the virus.

Schools have reopened partially or are starting to reopen in New York City, Chicago, Boston and other cities. But conflict between elected officials who support reopening and teachers’ unions seems likely to continue in places like Los Angeles, San Francisco and Portland, despite the new guidelines.

School district leaders have long asked for clearer guidelines from the federal government on how they should make decisions during the pandemic. The C.D.C.’s advice comes as a relief to many experts who have been frustrated at the low priority given to schools in local reopening plans.

“It’s not saying if you open schools again,” said Helen Jenkins, an infectious disease expert at Boston University and an adviser to the public schools district in Cambridge, Mass. “It’s saying, ‘You are going to open schools again, and this is how to do it,’ which I appreciate.”

The agency’s approach struck the right balance between the risks and the benefits of in-person instruction, said Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.

“We have accumulated a tremendous amount of harms from not having schools open,” Dr. Nuzzo said. “This document is important in trying to couch the risks in relation to those harms, and try to paint a path forward.”

The C.D.C. encouraged elementary schools to remain open regardless of virus levels in the surrounding community, pointing to evidence that young students are least likely to be infected or to spread the virus. Middle schools and high schools should switch to virtual learning only when community transmission of the coronavirus reaches the highest level, the agency said.

The agency also prioritized in-person instruction over extracurricular activities like sports and school events. In an outbreak, these activities should be curtailed before classrooms are closed, officials said.

Some experts raised concerns about the strategy.

Most school districts are in communities where viral transmission is already at or close to levels that the agency has deemed to be the highest risk, for example. Yet many have kept schools open without experiencing outbreaks of the virus.

“Most of the United States is sending their kids to school at above that cutoff,” said Dr. Jacqueline Grupp-Phelan, chief of pediatric emergency medicine at the University of California, San Francisco. “I’m not sure it’s going to make an impact on them, because they’re doing it and they’ve done it safely.”

Teachers and supporters demonstrating this month outside Samuel Gompers Public School in Philadelphia. Notably absent from the C.D.C. guidance are recommendations on improving ventilation in schools.
Teachers and supporters demonstrating this month outside Samuel Gompers Public School in Philadelphia. Notably absent from the C.D.C. guidance are recommendations on improving ventilation in schools.Credit…Matt Rourke/Associated Press
Cecilia Krizmanich, left, a teacher at Joyce Kilmer Elementary in Chicago, helped set up Marvin Araujo-Avilas’s computer on the first day of in-person classes on Thursday. Only two students showed up. Credit…Taylor Glascock for The New York Times

Notably absent from the agency’s guidance were recommendations on improving ventilation in schools, an important safeguard now that the coronavirus is known to be carried aloft in tiny airborne particles.

In one short paragraph, the C.D.C. suggested that schools open windows and doors to increase circulation, but said they should not be opened “if doing so poses a safety risk or a health risk.”

“C.D.C. gives lip service to ventilation in its report, and you have to search to find it,” said Joseph Allen, an expert on building safety at the Harvard T.H. Chan School of Public Health in Boston. “It’s not as prominent as it should be.”

The section on ventilation does link to more information online. But all of that is buried, relative to a misguided emphasis on cleaning surfaces like outdoor playground equipment, said Linsey Marr, an expert in airborne transmission of viruses at Virginia Tech.

“I think the balance is incorrect in putting so much emphasis on cleaning surfaces and almost no emphasis on cleaning the air, given what we know about how the virus spreads,” she said.

Ideally, the C.D.C. should also have mentioned high-quality masks or double-masking, Dr. Allen said. (The agency on Thursday released new advice for masking that included the use of two masks at once.)

Other preventive measures the C.D.C. recommended for schools are those it has previously endorsed: universal masking of staff and students; physical distancing; hand-washing and hygiene; cleaning; and contact tracing, in combination with isolation for those who have tested positive and quarantine for those who have been exposed to the virus.

The agency advised that schools refer all symptomatic students, teachers, staff and close contacts for diagnostic testing, and that schools put in place routine weekly testing of students and staff, except when community transmission is low. But the expense and logistics of widespread screening would be a heavy burden for school districts.

The C.D.C. skated lightly over physical distancing. “The agency’s previous recommendation for distancing suggested that schools have students attend on alternating schedules, in order to reduce the number of students in classrooms and hallways.”

The new guidance instead says schools should put in effect physical distancing “to the greatest extent possible,” but requires it only when community transmission of the virus is high. The softer emphasis makes the guidelines more feasible for school districts to follow, Dr. Nuzzo said.

“A lot of communities have pursued hybrid approaches, or in some cases just not opened, because they haven’t been able to figure out that spacing issue,” she said. The guidelines give the impression that maintaining at least six feet of distance between students is ideal, “but the whole attempt to bring kids back to school doesn’t have to break down over that,” she added.

The six-feet rule has been embraced as an orthodoxy, however, by many educators. Becky Pringle, president of the National Education Association, the country’s largest teachers union, said there should be no wiggle room on physical distancing or other mitigation strategies.

A socially distanced gym class in Provo, Utah.Credit…George Frey/Getty Images
A student entered Joyce Kilmer Elementary in Chicago, where schools are reopening after protracted disagreements with the teachers’ union.Credit…Taylor Glascock for The New York Times

“We need detailed guidance from the C.D.C. that doesn’t leave room for political games,” she said. “This is an airborne disease. Masks must be mandated, social distancing must be in place and proper ventilation is a must.”

As it had previously, the C.D.C. recommended using two measures to determine the risk of transmission in the community: the total number of new cases per 100,000 people, and the percentage of positive test results over the previous seven days.

The agency established four risk levels whose thresholds do not significantly differ from previous recommendations, except that the data are evaluated over seven days instead of 14 — a change that may allow schools to respond more quickly to shifting virus prevalence in their communities.

Dr. Jenkins of Boston University said the percentage of positive tests can vary with how much testing a community is doing. And the highest levels of community spread defined by the agency — 10 percent positivity, and 100 cases per 100,000 people over the previous seven days — are too conservative, she and other experts said.

“I do worry that there might be an impact on unnecessarily delaying the opening for the middle- and high school students,” said Dr. Grupp-Phelan of the University of California, San Francisco.

She added that her hospital, in a region where most middle- and high schools are closed, had seen large increases in adolescents who were suicidal or had developed eating disorders.

President Biden has pledged to open the majority of K-8 schools within the first 100 days of his administration. But on Wednesday, the White House press secretary, Jen Psaki, said that the president had been referring to in-person teaching “at least one day a week.”

That goal is already in reach: A majority of districts are offering at least some in-person learning, and about half the nation’s students are reporting to classrooms. The divide often falls along political lines. Conservative areas are likely to have open schools, while in liberal cities and suburbs, where teachers’ unions are influential, schools are more likely to be operating remotely.

Many districts, particularly ones in the South and the middle of the country, have offered fully in-person instruction for some or all grades at times when virus levels have risen far above what the C.D.C. says is advisable.

According to the agency’s guidelines, the approximately one-third of schools that remain entirely virtual may be too cautious.

Students received hand sanitizer before entering P.S. 316 in Brooklyn in December.Credit…Anna Watts for The New York Times
Temperature checks at Joyce Kilmer Elementary in Chicago on Thursday.Credit…Taylor Glascock for The New York Times

If the new recommendations had been in place last fall, for example, San Francisco could have opened all of its schools for fully in-person instruction in mid-September (although the city may have chosen to close middle- and high schools as cases began climbing in November).

Today, according to the guidelines, San Francisco could open elementary schools in a hybrid mode, and is close to being able to open middle- and high schools in a hybrid mode.

Instead the city’s schools have been shuttered since the pandemic began, and the district has agreed to far more restrictive reopening standards with its union. Officials have set no date for bringing young children back to school, and have said they do not expect most middle- and high school students to return in person this year.

Rebecca Bodenheimer is a mother of a third-grader in Oakland, Calif., and an organizer of a parent group that has been pushing the city’s school district, which is currently all virtual, to set a date for reopening.

The C.D.C.’s guidelines sounded reasonable, Ms. Bodenheimer said. But she was not sure they would sway a debate that was emotional for many.

“The research and data have been piling up about the fact that schools can open safely, and those people who are just only operating on unfounded fear — I don’t see a lot of them coming around,” she said.

Some local unions continue to fight reopening efforts, demanding that teachers be vaccinated before returning to classrooms. The new guidance recommended that states immunize teachers in early phases of the rollout but said access to vaccines should “nevertheless not be considered a condition for reopening schools for in-person instruction.”

Vaccinating teachers is very effective at cutting down cases in both teachers and students in a model of transmission in high schools, said Carl Bergstrom, an infectious diseases expert at the University of Washington in Seattle. “It should be an absolute priority,” he said.

Still, he added, “I can certainly see why they chose not to make it a prerequisite, because it may not be something that can be done in time to have schools open.”

Teachers’ unions have also asked for stringent protections regarding hygiene and air quality inside school buildings.

In Boston, for example, air quality was a major point of contention in reopening negotiations between the school district and teachers’ union. The agreement that paved the way to students returning to schools called for air purifiers in classrooms and a system for testing and reporting air quality data.

Ms. Pringle, the union president, said her members continue to be concerned about aging school buildings that do not include modern ventilation systems. Those schools were more likely to be located in lower-income and nonwhite communities hit hardest by the pandemic.

Many teachers have “no trust” that school administrators will put strong virus safety measures in place or will be given the funding to do so, Ms. Pringle said: “That’s why you see educators rising up across the country and saying, ‘At least give us the vaccine.’”

Dental Practices Change in the Covid Era

Less Drilling, Less Germ Spray: Dentistry Adapts to the Covid Era

The pandemic has forced dentists and hygienists to change some of the methods for maintaining good oral hygiene, to protect patients as well as themselves.

Dr. Todd Kandl performs a root canal at his dentistry practice in East Stroudsburg, Pa., with extra Covid precautions, including an external oral air scrubber, an oral dental dam on the patient and extra layers of protective clothing.
Dr. Todd Kandl performs a root canal at his dentistry practice in East Stroudsburg, Pa., with extra Covid precautions, including an external oral air scrubber, an oral dental dam on the patient and extra layers of protective clothing.Credit…Jonno Rattman for The New York Times

  • Feb. 9, 2021, 2:30 a.m. ET

Ann Enkoji normally enjoys seeing her dental hygienist, but when her dentist’s office in Santa Monica, Calif., canceled her cleaning visit last spring, she felt relieved.

She had been wary of keeping the appointment anyway, worried about someone else’s fingers and instruments exploring her mouth at a time when more than 25,000 Americans were contracting the coronavirus daily.

“It’s just too up close in that mouth-nasal region,” said Ms. Enkoji, 70, a marketing design consultant based in Santa Monica.

When she returned to her dentist’s office in September for a cleaning, she was asked to wash her hands and use an antimicrobial mouth rinse, steps that federal health guidance said might help curb the spread of germs in aerosol and splatter during treatment.

Without a doubt, dentistry is among the more intimate health professions. Patients must keep their mouths wide open as dentists and hygienists poke around inside with mirrors, scalers, probes and, until recently, those cringe-inducing drills.

Such drills and other power equipment, including ultrasonic scalers and air polishers, can produce suspended droplets or aerosol spray that may hang in the air, potentially carrying the virus that could endanger patients and staff.

Today, dental offices operate in a markedly different way than they did pre-pandemic. Since reopening in May and June, they have been following federal guidelines and industry group recommendations aimed at curtailing the spread of Covid.

Los Angeles County, where Ms. Enkoji lives, passed 1.4 million in cases, and New York City has reported more than half a million cases.

And while vaccination offers fresh promise, there are new worries about more contagious variants of the virus as well as a months-long timetable for rolling out the vaccines to the general public.

Many dental offices have stayed open in recent months, with dentists and hygienists geared up in face shields, masks, gowns, gloves and hair covers resembling shower caps. They have set aside aerosol-spewing power equipment, and hygienists instead rely on traditional hand tools to remove patients’ built-up plaque and tartar.

Under the new practices, patients typically get called a few days before visits and are asked if they have any Covid symptoms. They may be told to wait in their cars until they can be seen. Their temperatures may be taken before entering a dental office, and they have to wear masks, except during treatment, all measures recommended by the U.S. Centers for Disease Control and Prevention.

Dental offices also look different now. Many dentists are allowing only one patient in the office at a time. At Exceptional Dentistry on Staten Island, the waiting area is bereft of magazines, and plexiglass shields have been installed at the front desk, said Dr. Craig Ratner, owner of the office in the Tottenville neighborhood.

Donning a face shield over his cap, Dr. Kandl wears two masks, a surgical gown and dental loupes.Credit…Jonno Rattman for The New York Times
A dental dam is used to isolate a work area and to cover a patient’s mouth.Credit…Jonno Rattman for The New York Times

And visits may last longer, because scaling by hand is more laborious than applying ultrasonic scalers, and because some patients have built-up tartar, stains and plaque on their teeth stemming from pandemic-related gaps in visits, said Dr. Ratner, who is president of the New York State Dental Association.

“It’s unfortunate, but understandable,” he said.

This revolution in dental protective gear has been compared to the one that accompanied the HIV/AIDS pandemic, when many dental workers began wearing gloves and masks for the first time, according to an article in the journal JDR Clinical & Translational Research.

“Dentistry has changed — it’s incredible how it has changed over the last few months,” said Dr. Donald L. Chi, a pediatric dentist and professor of oral health sciences and health services at the University of Washington.

Covid-19 had barely touched the United States early last February when Dr. William V. Giannobile, dean and professor at the Harvard School of Dental Medicine in Boston, heard from a counterpart in Wuhan, China.

The dean of the dental school in Wuhan, where the coronavirus was first been reported on New Year’s Eve in 2019, asked Dr. Giannobile if he would help get his team’s findings republished in the United States.

The authors of the article, which would appear in The Journal of Dental Research, laid out basic safety measures that would later be adopted by thousands of U.S. dentists.

“They showed that the provision of dental care is safe and that guidelines could be put in place to triage patients and provide dental care,” Dr. Giannobile said.

Those guidelines include not only the now-ubiquitous use of staff protective gear, but also pre-visit questions and temperature checks and patients’ use of masks. And the Wuhan researchers stated that “in areas where Covid-19 spreads, nonemergency dental practices should be postponed” — advice endorsed early last year by the C.D.C. and the American Dental Association.

The springtime shuttering of dental businesses caused a lot of hardship for many dental practices. Only 3 percent of those offices in the United States stayed open in March and April, and layoffs and furloughs led to the disappearance of more than half of dental-office jobs, said Marko Vujicic, the chief economist for the A.D.A.

“This was an unprecedented event in dentistry,” Mr. Vujicic said. But when doors swung open later in the spring, the number of patients soared.

His association has been seeking permission to provide tests for the virus nationwide, as well as to administer Covid vaccines. Dentists were allowed to administer the vaccine in 20 states, including California, Connecticut, New Jersey and New York, A.D.A. research showed.

Dr. Donald L. Chi, who practices at the Odessa Children’s Clinic in Seattle, says that one way that he avoids drilling — and unnecessarily spreading the virus — is to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.
Dr. Donald L. Chi, who practices at the Odessa Children’s Clinic in Seattle, says that one way that he avoids drilling — and unnecessarily spreading the virus — is to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.Credit…Jovelle Tamayo for The New York Times

Dentists rank high on the priority lists for those eligible to get the vaccine, with Phase 1a status in 40 states. The C.D.C. recommends that dental hygienists and assistants also be included on the vaccine priority list.

In New York City, the College of Dentistry at New York University suspended in-person visits last winter, but resumed urgent cases in late June. Since then, it has treated more than 700 patients a day, said Elyse J. Bloom, associate dean of the college. And its mandatory virus testing for students and members of the faculty and the staff has helped keep the college’s count of positive cases significantly lower than that of New York City over all, she said.

Fear of job losses has rippled through the industry.

“This was a very frightening time for many individuals,” said JoAnn Gurenlian, a professor of dental hygiene at Idaho State University who heads a return-to-work task force for the American Dental Hygienists Association.

More than half of dental hygienists, dental therapists and oral health specialists reported that they were not working in a June 2020 survey conducted by the International Federation of Dental Hygienists. Half said they were deeply concerned that they would not have enough personal protective gear to treat patients.

Patients, too, have been anxious. Some dentists have found themselves treating stressed clients who were grinding their teeth in their sleep and needed devices to prevent chips or fractures.

“Honestly, I’ve made a lot of night guards,” said Dr. Todd C. Kandl, who has spent 13 years building up his family practice with a staff of eight in East Stroudsburg, Pa., tucked away in the Poconos.

Forced to close the practice in mid-March, Dr. Kandl received a federal loan that allowed him to reopen on June 1. In between, he tried to diagnose patients’ conditions over the phone, he said. Now, most of his patients have come back.

He and his staff follow C.D.C. guidelines by putting on a clean gown for each patient and changing it afterward. They launder all gowns at the office.

He has installed a number of the upgrades recommended by the C.D.C., including high-efficiency particulate air, or HEPA, filter units to trap fine particles. And he purchased several suction systems that remove droplets and aerosols, as well as ultraviolet light to help sanitize.

Dr. Kandl also chose to discontinue use of nitrous oxide, a gas used to mildly sedate and relax anxious dental patients. In the past, he rarely used the gas, but amid the Covid-19 outbreak, he grew concerned about his system, an older type that wasn’t worth the risk of exposing patients.

Lynn Uehara, 55, the business manager for a Hawaii family dental practice, said that island living had resulted in shipping problems to obtain the protective gear that her employees need.

“Our masks and gloves are being rationed by our main dental suppliers,” Mrs. Uehara said. Gowns ordered four months ago finally arrived. And prices are soaring. “We used to pay about $15 for a box of gloves. Now they are charging us $40 to $50 a box.”

But like other dental workers, she is now a veteran of uncertainty. If the lack of protective gear means reducing the number of patients, “then that’s what we will do,” she said.

Dental tools await sterilization at Dr. Kandl’s office.Credit…Jonno Rattman for The New York Times
A U.V. sterilizer in Dr. Kandl’s office.Credit…Jonno Rattman for The New York Times

The Uehara family has offices in Honolulu on Oahu and in Hilo, on the Big Island of Hawaii. The pandemic lockdowns hurt its practices. Family members commute between the two islands by commercial jet, posing another risk.

The reopening went slowly, but patients have returned. “I’ve heard the sound of laughter back in the office,” Mrs. Uehara said.

A surge in coronavirus cases among children has also posed challenges for pediatric dentists.

In early December, the C.D.C. strongly endorsed school-based programs in which dentists apply thin coatings called sealants on the back teeth of children in third through fifth grades. Such sealants are especially helpful for children at risk of cavities and for children whose families can’t afford private dentists, the agency said.

Dr. Chi, the pediatric dentist and University of Washington professor, said that dentistry was turning to more conservative methods of dealing with tooth decay now that some drills and tools might heighten the risk of contagion.

Dr. Chi, who practices at the Odessa Children’s Clinic in Seattle, said that one way that he avoided drilling was to place silver diamine fluoride on a child’s baby tooth to prevent a cavity from growing.

He can also select stainless steel crowns to block the growth of a cavity. Applying such crowns normally requires numbing the tooth, using a drill to remove decay and reshape the tooth, and then installing the crown.

A more conservative approach: placing a crown directly on the baby tooth without removing decay or reshaping. Evidence suggests that it is as effective as the traditional approach, takes less time and is more cost-effective, Dr. Chi said.

“Covid has really encouraged dentists to look at all the options you have to treat dental disease,” he said.

Some dentists, however, may choose to leave the profession. The A.D.A. conducted a survey asking dentists how they would react if their patient visits remained the same for several months.

“Our data show that 40 percent of dentists 65 and older would seriously consider retiring in the coming months if patient volume remains at what it is today,” Dr. Vujicic said.

Over time, though, some patients have learned to adjust.

Enid Stein of Staten Island has visited Dr. Ratner’s practice five times since it reopened, for implant surgery and new crowns. A self-described germaphobe who carries alcohol spray in her pocketbook, she brought her own pen to pay by check.

“I’m done, thank God,” she said. “Not that I don’t mind seeing him and all the girls in the office, but I’m in good shape.”

Deep-Cleaning Videos Are Getting Grosser

Deep-Cleaning Videos Are Getting Grosser

Stuck at home, people are excavating the mold in their dishwashers and the hair in their drains for your viewing pleasure.

Allison Nelson removes grease from ovens and shares toilet cleaning tips in her TikTok videos.
Allison Nelson removes grease from ovens and shares toilet cleaning tips in her TikTok videos.

  • Feb. 3, 2021, 9:00 a.m. ET

A little over 12 minutes into the video “Disaster Clean With Me 2021,” Becky Moss holds her vacuum’s dirt cup up to the camera for inspection. It’s filled with a powdery mound of gray dust and a swirl of pet hair. The volume of material — two or three cups worth, from the looks of it — seems excessive for one room. And yet, the accumulation is so satisfying to see.

“My husband is like, ‘That is so gross. How can you film this?’” said Ms. Moss, a 26-year-old YouTuber in Oxford, Mich., who started her channel in May 2020. “I always tell him, ‘This is what people want to see.’”

Videos like hers abound on YouTube, where legions of home-improvement influencers post time-lapse recordings of their chores. Their “clean with me” uploads inspire people to tackle their own messes, however big or small. In 2020, the number of “clean with me” videos on YouTube rose by 50 percent, according to the company, and the number of “organize with me” videos nearly doubled.

During lockdown, the deep-cleaning phenomenon spread to TikTok — and morphed into something more grotesque. Users post videos revealing vile filth in the forgotten corners and crevices of their homes. The footage has found a captive audience during the pandemic, a period marked for many by more time spent at home, a strong urge to nest and obsessive sanitization.

All in all, TikTok videos that include the #cleaning hashtag have accounted for some 7.6 billion views; the company said it saw engagement spike in December after a user posted a video coining the portmanteau “CleanTok.” These videos tend to be hyper-focused: Rather than tidying entire rooms, creators unscrew their moldy dishwasher filters and fish yards of scummy hair from their shower drains, sparing none of the slimy details.

Through TikTok’s “duet” feature, people can replicate these dirty jobs side by side with original “how-to” videos. The videos also further boost the cultlike followings behind brands like Scrub Daddy, Fabuloso and Dawn (as well as the classic combo of baking soda and vinegar). TikTok has also worked with companies like Bounty and Lysol on hashtag campaigns.

In all of these cleaning videos, some trends have emerged. One, known as “laundry stripping,” involves pouring Borax and laundry detergent into one’s bathtub, creating a deep soak for old sheets, sweat-stained shirts and even college dorm couch cushions. After hours of soaking, the bath water appears reliably brown.

Redditors have been sharing similar content for years on Oddly Satisfying: a hub of slime, kinetic sand, soap cutting, power washing and upholstery cleaning.

Mitchell Creed, a 35-year-old neurology resident at Stony Brook Children’s Hospital, created the subreddit in 2013 to capture the inexplicable euphoria in little perfections. “When we have cleaning videos, it kind of just goes back to that simplicity of life and things that are just neat and ordered,” he said.

And in a year of compounded crises, the ability to make meaning out of mess has brought people some comfort. “The best way to manage anxiety is to find something that you can control,” said Alicia Clark, a psychologist and the author of “Hack Your Anxiety.” “Our immediate environments and cleaning them is just right in front of us.”

While TikTok’s 60-second format can create a fantasy by editing out most of the elbow grease — “It’s like Disney, the ‘happily ever after’ of the house project,” Dr. Clark said — it could be highly motivational for those struggling with where to start. “I can’t help but think that it’s constructive,” Dr. Clark said. Some videos, on the other hand, show only the mess, leaving viewers wondering whether they should even entertain the idea of a deep clean.

The videos also have their heartwarming moments. One trend on TikTok involves family members or friends tidying a loved one’s space, often as a surprise.

Allison Nelson, 29, a cleaning professional from Denver, loves reading comments from her viewers on TikTok. “One of my favorites I get all the time is peeps writing, sending videos and duetting my videos and pictures of my tips and tricks that they have applied to their own home and are loving,” Ms. Nelson said. She said the app has also helped her business, Allisonscleanin Service, which now has a waiting list.

On YouTube, Ms. Moss has seen similar good fortune. “It’s not just a hobby anymore,” she said. “It’s turned into me contributing financially to my family.”

Captivating as the videos may be, there’s nothing more satisfying than doing the cleanup yourself. After all, when’s the last time you looked at your baseboards?

What You Can Do to Avoid the New Coronavirus Variant Right Now

Ask Well

What You Can Do to Avoid the New Coronavirus Variant Right Now

It’s more contagious than the original and spreading quickly. Upgrade your mask and double down on precautions to protect yourself.

Credit…Getty Images
Tara Parker-Pope

  • Jan. 19, 2021Updated 3:44 p.m. ET

New variants of the coronavirus continue to emerge. But one in particular has caused concern in the United States because it’s so contagious and spreading fast. To avoid it, you’ll need to double down on the same pandemic precautions that have kept you safe so far.

The variant known as B.1.1.7., which was first identified in Britain, doesn’t appear to cause more severe disease, but it has the potential to infect an estimated 50 percent more people. The Centers for Disease Control and Prevention has predicted that this variant could become the dominant source of infection in the United States by March. Variants with the same mutation have been reported in Brazil and South Africa, and now scientists are studying whether a variant with a different mutation, and first found in Denmark, has caused a surge in cases in California.

The new variant spreading in the United States appears to latch onto our cells more efficiently. (You can find a detailed look inside the variant here.) The change suggests it could take less virus and less time in the same room with an infected person for someone to become ill. People infected with the variant may also shed larger quantities of virus, which increases the risk to people around them.

“The exact mechanism in which it’s more transmissible isn’t entirely known,” said Nathan D. Grubaugh, assistant professor and epidemiologist at the Yale School of Public Health. “It might just be that when you’re infected, you’re exhaling more infectious virus.”

So how do you avoid a more-contagious version of the coronavirus? I spoke with some of the leading virus and infectious disease experts about what makes the new variant so worrisome and what we can do about it. Here’s what they had to say.

How can I protect myself from the new coronavirus variant?

The variant spreads the same way the coronavirus has always spread. You’re most likely to contract the virus if you spend time in an enclosed space breathing the air of an infected person. The same things that have protected you from the original strain should help protect you from the variant, although you may need to be more rigorous. Wear a two- or three-layer mask. Don’t spend time indoors with people not from your household. Avoid crowds, and keep your distance. Wash your hands often, and avoid touching your face.

“The first thing I say to people is that it’s not a different virus. All the things we have learned about this virus still apply,” said Dr. Ashish K. Jha, dean of the Brown University School of Public Health. “It’s not like this variant is somehow magically spreading through other means. Anything risky under the normal strain just becomes riskier with the variant.”

And let’s face it, after months of pandemic living, many of us have become lax about our Covid safety precautions. Maybe you’ve let down your guard, and you’re spending time indoors and unmasked with trusted friends. Or perhaps you’ve been dining in restaurants or making more trips to the grocery store each week than you did at the start of lockdowns. The arrival of the variant means you should try to cut back on potential exposures where you can and double down on basic precautions for the next few months until you and the people around you get vaccinated.

“The more I hear about the new variants, the more concerned I am,” said Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists. “I think there is no room for error or sloppiness in following precautions, whereas before, we might have been able to get away with letting one slide.”

Should I upgrade my mask?

You should be wearing a high-quality mask when you run errands, go shopping or find yourself in a situation where you’re spending time indoors with people who don’t live with you, Dr. Marr said. “I am now wearing my best mask when I go to the grocery store,” she said. “The last thing I want to do is get Covid-19 in the month before I get vaccinated.”

Dr. Marr’s lab recently tested 11 mask materials and found that the right cloth mask, properly fitted, does a good job of filtering viral particles of the size most likely to cause infection. The best mask has three layers — two cloth layers with a filter sandwiched in between. Masks should be fitted around the bridge of the nose and made of flexible material to reduce gaps. Head ties create a better fit than ear loops.

Covid-19 Vaccines ›

Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

If you don’t want to buy a new mask, a simple solution is to wear an additional mask when you find yourself in closer proximity to strangers. I wear a single mask when I walk my dog or exercise outdoors. But if I’m going to a store, taking a taxi or getting in the subway, I double mask by using a disposable surgical mask and covering it with my cloth mask.

Do I need an N95 medical mask?

While medical workers who come into close contact with sick patients rely on the gold-standard N95 masks, you don’t need that level of protection if you’re avoiding group gatherings, limiting shopping trips and keeping your distance from others.

“N95s are hard to get,” said Dr. Jha. “I don’t think people should think that’s what they need. Certainly there are a lot of masks out in the marketplace that are pretty good.”

If you’re working in an office or grocery store, or find yourself in a situation where you want added mask protection, you can get an alternative to the N95. Dr. Jha suggested using a KF94 mask, a type of mask made in South Korea that can be purchased easily online. It resembles an N95, with some differences. It’s made of a similar nonwoven material that blocks 94 percent of the hardest-to-trap viral particles. But the KF94 has ear loops, instead of elastic head bands, so it won’t fit as snugly as an N95.

The KF94 is also disposable — you can buy a pack of 20 for about $40 on Amazon. While you can let a KF94 mask air dry and reuse it a few times, it can’t be laundered and won’t last as long as a cloth mask. One solution is to save your KF94 mask for higher risk situations — like riding a subway, spending time in a store or going to a doctor’s appointment. Use your cloth mask for outdoor errands, exercise or walking the dog.

Are there additional ways to reduce my risk?

Getting the vaccine is the ultimate way to reduce risk. But until then, take a look at your activities and try reducing the time and number of exposures to other people.

For instance, if you now go to the store two or three times a week, cut back to just once a week. If you’ve been spending 30 to 45 minutes in the grocery store, cut your time down to 15 or 20 minutes. If the store is crowded, come back later. If you’re waiting in line, be mindful of staying at least six feet apart from the people ahead of you and behind you. Try delivery or curbside pickup, if that’s an option for you.

If you’ve been spending time indoors with other people who aren’t from your household, consider skipping those events until you and your friends get vaccinated. If you must spend time with others, wear your best mask, make sure the space is well ventilated (open windows and doors) and keep the visit as short as possible. It’s still safest to take your social plans outdoors. And if you are thinking about air travel, it’s a good idea to reschedule given the high number of cases around the country and the emergence of the more contagious variant.

“The new variants are making me think twice about my plan to teach in-person, which would have been with masks and with good ventilation anyway,” Dr. Marr said. “They’re making me think twice about getting on an airplane.”

Will the current Covid vaccines work against the new variants?

Experts are cautiously optimistic that the current generation of vaccines will be mostly effective against the emerging coronavirus variants. Earlier this month, Pfizer and BioNTech announced that their Covid vaccine works against one of the key mutations present in some of the variants. That’s good news, but the variants have other potentially risky mutations that haven’t been studied yet.

Some data also suggest that variants with certain mutations may be more resistant to the vaccines, but far more study is needed and those variants haven’t yet been detected in the United States. While the data are concerning, experts said the current vaccines generate extremely high levels of antibodies, and they are likely to at least prevent serious illness in people who are immunized and get infected.

“The reason why I’m cautiously optimistic is that from what we know about how vaccines work, it’s not just one antibody that provides all the protection,” said Dr. Adam Lauring, associate professor of infectious disease at the University of Michigan. “When you get vaccinated you generate antibodies all over the spike protein. That makes it less likely that one mutation here or there is going to leave you completely unprotected. That’s what gives me reason for optimism that this is going to be OK in terms of the vaccine, but there’s more work to be done.”

If I catch Covid-19, will I know if I have the new variant?

Probably not. If you test positive for Covid-19, the standard PCR test can’t definitively determine if you have the variant or the original strain. While some PCR test results can signal if a person is likely to be infected with a variant, that information probably won’t be shared with patients. The only way to know for sure which variant is circulating is to use gene sequencing technology, but that technology is not used to alert individuals of their status. While some public health and university laboratories are using genomic surveillance to track the prevalence of variants in a community, the United States doesn’t yet have a large-scale, nationwide system for checking coronavirus genomes for new mutations.

Treatment for Covid-19 is the same whether you have the original strain or the variant. You can read more about what to do if you get infected here.

Are children more at risk from the new variant?

Children appear to get infected with the variant at about the same rate as the original strain. A large study by health officials in Britain found that young children are only about half as likely as adults to transmit the variant to others. While that’s good news, the highly contagious nature of the variant means more children will get the virus, even if they are still proportionately less contagious and less prone to getting infected than adults. You can learn more here.

If I’ve already had Covid-19, am I likely to have the same level of immunity to the new strain?

Most experts agree that once you’ve had Covid-19, your body has some level of natural immunity to help fight off a second infection — although it’s not known how long the protection lasts. The variants circulating in Brazil and South Africa appear to have mutations that allow the virus to evade natural antibodies and reinfect someone who has already had the virus. The concern is based on lab tests using antibodies of people with a previous infection, so whether that translates to more reinfections in the real world isn’t known. The effect of the vaccine against these variants isn’t known yet either. While all of this sounds frightening, scientists are hopeful that even if the vaccines don’t fully protect against new variations of the virus, the antibodies generated by the vaccine still will protect people from more serious illness.

A Night in the Hospital, From Both Ends of the Stethoscope


A Night in the Hospital, From Both Ends of the Stethoscope

As a doctor writing about medical errors, I saw potential risks lurking everywhere when my daughter was hospitalized with appendicitis.

Credit…Xiao Hua Yang

  • Jan. 5, 2021, 5:00 a.m. ET

Just as the first coronavirus reports were emerging from China in late 2019, the medical world was observing the 20th anniversary of “To Err is Human,” the seminal report from the Institute of Medicine that opened our eyes to the extent of medical error. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. Those numbers remain difficult to accurately quantitate, but we know that they are not small.

The conversation has now been broadened to include all preventable harms to patients, even ones that are not errors per se. As I set about writing a book on medical error, I wanted to see both sides of the story. I drew upon my own experiences as a physician but also interviewed patients and families to get the view from the other side. But I soon realized that the distinction between those two “sides” was rather fluid.

Midway through writing the book, my teenage daughter experienced a stomachache. My kids know that fevers, colds, coughs and sprained ankles do not get my pulse up, and that “if you’re not bleeding out or in cardiac arrest” they should seek medical sympathy from their computer programmer father. They often accuse me of ignoring their medical complaints altogether, but as a primary care doctor I know that most aches and pains of daily life get better on their own and are best left unobsessed about.

But this time I became suspicious of my daughter’s inability to find a comfortable position and so pulled out my stethoscope. When I heard complete silence instead of gurgling bowel sounds, I shuttled us straight to my hospital’s E.R. My correct diagnosis of appendicitis modestly redeemed me in my daughter’s eyes, though she was mortified that I chatted it up with colleagues.

Surgery was planned for the next morning, so I stayed in her hospital room overnight, reading the stack of journal articles I’d been reviewing for my book. Hospitals have always been a comfortable setting for me, but the familiar ward suddenly felt apocalyptic, with medical errors and harms lurking everywhere. The population of a midsize city traipsed in and out of my daughter’s room that night, each armed with potentially dangerous things to administer or extricate. And even if they were all batting 99 percent, the denominator of “things” was so enormous that some amount of error was all but guaranteed.

When the pediatric resident arrived at 3 a.m. to assess my daughter — after she’d been evaluated by the triage nurse, the E.R. resident, the E.R. attending, the surgery resident, the surgery chief, and then the surgery attending — I put my foot down.

“She’s on pain meds now,” I hissed, “so you won’t find any abdominal tenderness. And the ultrasound already showed an inflamed appendix.” The resident eyed me warily, clearly calculating the risk/benefit ratio of pressing her case with an ornery, sleep-deprived parent.

“But if you are going to wake her up, jab on her belly, and then come to the grand conclusion that she has appendicitis and needs surgery, forget about it,” I snapped. The resident backed off, and I flopped back into my chair to read yet another cheery article about medical calamities.

The surgery team came by with another option: giving just IV antibiotics, with no operation. With antibiotics alone, they said, there was a 50 percent chance of appendicitis recurring. Which meant that for half the patients, surgery could be avoided altogether. But we had to decide right away so they could know whether to book the O.R.

I asked the surgery resident how strong the data were. I wasn’t going to make a half-baked decision just because he was time-pressed to set the O.R. schedule. He groaned mightily but stood by while I searched up some studies. The data were preliminary but seemed encouraging.

Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though she’s a head taller than me. So I was sure she’d jump at the chance to avoid surgery.

It turned out that she had an utterly different take. The experience of getting an IV in the E.R. was so miserable that she never wanted to repeat it. The definitiveness of surgery was much more appealing than the possibility — however small — of going through this again in the future.

The next morning, that dangly tail of residual colon was successfully snipped. When my daughter was coming out of anesthesia, I asked her if she’d like some Toradol, the pain medication that the nurse was offering. “Tortellini?” she mumbled foggily. “Are we having tortellini?”

I was impressed, yet again, by the marvels of modern medicine, knowing full well that had this taken place a century earlier I might have been digging a grave for my child that evening instead of digging through the freezer for tortellini.

As a physician, I’m stunningly proud of the medical care our hospitals can provide. But during our stay as civilians, every aspect felt like harm waiting to happen. I’m sure I ruffled a few feathers with all of my questions, but addressing family members’ worries is part of the job — even if the family member isn’t a physician, and isn’t on the faculty of that institution, and doesn’t coincidentally happen to be writing a book about medical error while sitting at the bedside.

It’s not comfortable being the squeaky wheel. Being on guard for my daughter 24/7 was frankly exhausting. But once you are on the patient side of the stethoscope, everything looks like a minefield.

Of course, the burden should not have to be on the patient or family for ensuring safe medical care. That is the job of the health care system. But as we well know, the system has not yet achieved pristine perfection, so it behooves patients and families to stay engaged as much as possible.

The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. But even the most dedicated staff need extra sets of eyes on the ground.

My advice to patients is to be polite but persistent. Don’t let unspoken annoyance deter you. Offer appreciation for the things that are going well — and acknowledge that everyone is working hard! — but plow forward. At the very least, ask what each medication is and why you are getting it.

And if you are too nauseated or too sleepy or too feverish, don’t rack yourself with guilt because you are not interrogating every staff member. Get the rest you need. Before you doze off, though, use some leftover surgical tape to affix a sign across your chest that says “Wash your hands!”

The onus is on the medical system to make health care as safe as possible. But patients and families shouldn’t feel shy about taking a forthright role. Keeping those jumbo jets from falling out of the sky is a team effort, and the team includes the folks on both ends of the stethoscope.

Dr. Danielle Ofri practices at Bellevue Hospital in New York City and is a clinical professor of medicine at New York University. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error.”

Life After Covid: When Can We Start Making Plans?

When Can We Start Making Plans?

We asked Dr. Anthony S. Fauci and other experts when they thought life would start to feel more normal.

Credit…Vincent Neuberg
Tara Parker-Pope

  • Dec. 16, 2020, 5:00 a.m. ET

The United States moved one step closer to getting back to normal this week with the first Covid vaccinations of health care workers around the country. While the majority of Americans won’t get their shots until spring, the vaccine rollout is a hopeful sign of better days ahead. We asked Dr. Anthony S. Fauci, as well as several epidemiologists and health and science writers for The Times, for their predictions about the months ahead. Here’s what they had to say.

What advice do you have for families eager to celebrate the holidays with their loved ones?

“Do it by Zoom. Don’t let Junior come home and kill Grandma. Think of this like World War II — our soldiers didn’t get to fly home to eat turkey. My father was at Normandy. My mother was with the Red Cross in occupied Austria. They missed the holidays. Life went on. There were happier years later.” — Donald G. McNeil Jr., health and science reporter

Will we shake hands again?

“I’m not. I don’t know about you. I said that many, many months ago and the newspapers went wild with it. I’m sure people will get back to shaking hands. I think people will probably become more aware of personal hygiene and protecting yourself. That doesn’t mean nobody will shake hands again, nor does it mean everybody will go back to the way we did it again. Probably somewhere in between. Some people will be reluctant to shake hands. Some people will be washing hands a whole lot more than they ever did, even when Covid-19 is no longer around.” — Dr. Anthony S. Fauci

When would you personally feel comfortable returning to the office?

“When I’m vaccinated and everyone around me is.” — McNeil

Is my employer going to require me to to be vaccinated?

“Employers do have the right to compel their workers to be vaccinated once a vaccine is formally approved. Many hospital systems, for example, require annual flu shots. But employees can seek exemptions based on medical reasons or religious beliefs. In such cases, employers are supposed to provide a ‘reasonable accommodation’; with a coronavirus vaccine, a worker might be allowed to wear a mask in the office instead, or to work from home.” — Abby Goodnough, national health care correspondent

Will we ever go to a big, crowded, indoor party without a mask again?

“If the level of infection in the community seems substantial, you’re not going to have the parties with friends in congregant settings. If the level of infection is so low that risk is minuscule, you’re going to see back to the normal congregating together, having parties, doing that. If we want to get back to normal it gets back to my message: When the vaccine becomes available, get vaccinated.” — Dr. Fauci

Do we have to wait for 75 percent of the population to be vaccinated before we can travel again?

“I think traveling is going to start easing up as you get much less than that. I think it’s going to be gradual. There is no black and white, light switch on, light switch off.” — Dr. Fauci

How long will we be wearing masks?

“If you get herd immunity where there are no infections around, you wouldn’t have to wear a mask all the time. You might want to wear it if you were in a crowded situation, but you wouldn’t have to have the stringency you have now. Ultimately, I think you’re going to have to transition from wearing all the time, to wearing it under certain circumstances, to perhaps not having to wear it at all.” — Dr. Fauci

How will we know it’s safe to do normal things?

“First of all, it’s going to be expressed by the number of new cases that you see — the test positivity number. You’ve got to go as low as you can get. The best number is zero. It’s never going to be zero, but anywhere close to that is great.” — Dr. Fauci

When can we go to the movies or the theater?

“It depends on the uptake of the vaccine and the level of infection in the community. If you go to April, May, June and you really put on a full-court press and try to vaccinate everybody within a period of a few months, as you go from second to third quarter of the year, then you could likely go to movies, go to theaters, do what you want. However, it’s unlikely, given what we’re hearing about people’s desire to get vaccinated, that we’re going to have that degree of uptake. If it turns out that only 50 percent get vaccinated, then it’s going to take much, much longer to get back to the kind of normality that we’d like to see.” — Dr. Fauci

When will you eat in a restaurant?

“If more than half the population is vaccinated, I would feel a little less stressed and anxious when heading out to do errands I normally do. I might actually feel comfortable to eat in a restaurant or see friends again one day if this is possible.”— Vijaya L. Seegulam, research project manager, Boston University

When will you feel comfortable in a crowd?

“Once my family and I are vaccinated, I would change behaviors, except I can’t imagine being in a crowd or attending any crowded events until at least 80 percent of the population is vaccinated.”— Julie Bettinger, associate professor, University of British Columbia

When will restrictions start to ease up?

“I think widespread availability of vaccines will result in the further relaxation of most precautions by mid- to late summer 2021.” — Michael Webster-Clark, postdoctoral researcher, University of North Carolina at Chapel Hill

What will the new normal look like?

“The new normal will be continued masking for the next 12 to 18 months and possibly the next few years. This is a paradigm shift.” — Roberta Bruhn, epidemiology core co-director, Vitalant Research Institute

What will never return to normal?

“My relationships with people who have taken this pandemic lightly and ignored public health messages and recommendations.” — Victoria Holt, professor emeritus, University of Washington

What did you learn from pandemic life?

“Staying home with my children has taught me that life with fewer errands to run and activities to partake in is kind of nice. I think in the future we will cut down on our family obligations.” — Jennifer Nuzzo, associate professor, Johns Hopkins

What pandemic habit will you keep?

“I’m going to keep my mask, and wear it in crowds and on subways, particularly during cold and flu season. I used to get sick all the time, but I haven’t had a cold or sore throat in months. I really like not getting sick!”

What’s one thing you’ll never take for granted again?

“I won’t take traveling to my extended family for granted.” — Alicia Allen, assistant professor, University of Arizona

What has forever changed in your daily life?

“I will never again have to explain what an epidemiologist is.” — Janet Rich-Edwards, associate professor, Harvard

Contributors: Margot Sanger-Katz, Claire Cain Miller and Quoctrung Bui

The Swiss Cheese Model of Pandemic Defense

The Swiss Cheese Model of Pandemic Defense

It’s not edible, but it can save lives. The virologist Ian Mackay explains how.

The multilayered “Swiss cheese” model was devised in the 1990s to improve industrial safety. Ian Mackay, a virologist at the University of Queensland, recently adapted it for the coronavirus pandemic. “It’s important to use more slices to prevent those volatile holes from aligning and letting virus through,” he said.
The multilayered “Swiss cheese” model was devised in the 1990s to improve industrial safety. Ian Mackay, a virologist at the University of Queensland, recently adapted it for the coronavirus pandemic. “It’s important to use more slices to prevent those volatile holes from aligning and letting virus through,” he said.Credit…Ian M. Mackay


  • Dec. 5, 2020, 5:00 a.m. ET

Lately, in the ongoing conversation about how to defeat the coronavirus, experts have made reference to the “Swiss cheese model” of pandemic defense.

The metaphor is easy enough to grasp: Multiple layers of protection, imagined as cheese slices, block the spread of the new coronavirus, SARS-CoV-2, the virus that causes Covid-19. No one layer is perfect; each has holes, and when the holes align, the risk of infection increases. But several layers combined — social distancing, plus masks, plus hand-washing, plus testing and tracing, plus ventilation, plus government messaging — significantly reduce the overall risk. Vaccination will add one more protective layer.

“Pretty soon you’ve created an impenetrable barrier, and you really can quench the transmission of the virus,” said Dr. Julie Gerberding, executive vice president and chief patient officer at Merck, who recently referenced the Swiss cheese model when speaking at a virtual gala fund-raiser for MoMath, the National Museum of Mathematics in Manhattan.

“But it requires all of those things, not just one of those things,” she added. “I think that’s what our population is having trouble getting their head around. We want to believe that there is going to come this magic day when suddenly 300 million doses of vaccine will be available and we can go back to work and things will return to normal. That is absolutely not going to happen fast.”

Rather, Dr. Gerberding said in a follow-up email, expect to see “a gradual improvement in protection, first among the highest need groups, and then more gradually among the rest of us.” Until vaccines are widely available and taken, she said, “we will need to continue masks and other common-sense measures to protect ourselves and others.”

In October, Bill Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health, retweeted an infographic rendering of the Swiss cheese model, noting that it included “things that are personal *and* collective responsibility — note the ‘misinformation mouse’ busy eating new holes for the virus to pass through.”

“One of the first principles of pandemic response is, or ought to be, clear and consistent messaging from trusted sources,” Dr. Hanage said in an email. “Unfortunately the independence of established authorities like the C.D.C. has been called into question, and trust needs to be rebuilt as a matter of urgency.” A catchy infographic is a powerful message, he said, but ultimately requires higher-level support.

The Swiss cheese concept originated with James T. Reason, a cognitive psychologist, now a professor emeritus at the University of Manchester, England, in his 1990 book, “Human Error.” A succession of disasters — including the Challenger shuttle explosion, Bhopal and Chernobyl — motivated the concept, and it became known as the “Swiss cheese model of accidents,” with the holes in the cheese slices representing errors that accumulate and lead to adverse events.

The model has been widely used by safety analysts in various industries, including medicine and aviation, for many years. (Dr. Reason did not devise the “Swiss cheese” label; that is attributed to Rob Lee, an Australian air-safety expert, in the 1990s.) The model became famous, but it was not accepted uncritically; Dr. Reason himself noted that it had limitations and was intended as a generic tool or guide. In 2004, at a workshop addressing an aviation accident two years earlier near Überlingen, Germany, he delivered a talk with the title, “Überlingen: Is Swiss cheese past its sell-by date?”

In 2006, a review of the model, published by the Eurocontrol Experimental Center, recounted that Dr. Reason, while writing the book chapter “Latent errors and system disasters,” in which an early version of the model appears, was guided by two notions: “the biological or medical metaphor of pathogens, and the central role played by defenses, barriers, controls and safeguards (analogous to the body’s autoimmune system).”

The cheese metaphor now pairs fairly well with the coronavirus pandemic. Ian M. Mackay, a virologist at the University of Queensland, in Brisbane, Australia, saw a smaller version on Twitter, but thought that it could do with more slices, more information. He created, with collaborators, the “Swiss Cheese Respiratory Pandemic Defense” and engaged his Twitter community, asking for feedback and putting the visualization through many iterations. “Community engagement is very high!” he said. Now circulating widely, the infographic has been translated into more than two dozen languages.

Dr. Mackay, a creator of the “Swiss Cheese Respiratory Pandemic Defense.”
Dr. Mackay, a creator of the “Swiss Cheese Respiratory Pandemic Defense.”Credit…Faye Sakura for The New York Times

“This multilayered approach to reducing risk is used in many industries, especially those where failure could be catastrophic,” Dr. Mackay said, via email. “Death is catastrophic to families, and for loved ones, so I thought Professor Reason’s approach fit in very well during the circulation of a brand-new, occasionally hidden, sometimes severe and occasionally deadly respiratory virus.”

The following is an edited version of a recent email conversation with Dr. Mackay.

Q. What does the Swiss cheese model show?

A. The real power of this infographic — and James Reason’s approach to account for human fallibility — is that it’s not really about any single layer of protection or the order of them, but about the additive success of using multiple layers, or cheese slices. Each slice has holes or failings, and those holes can change in number and size and location, depending on how we behave in response to each intervention.

Take masks as one example of a layer. Any mask will reduce the risk that you will unknowingly infect those around you, or that you will inhale enough virus to become infected. But it will be less effective at protecting you and others if it doesn’t fit well, if you wear it below your nose, if it’s only a single piece of cloth, if the cloth is a loose weave, if it has an unfiltered valve, if you don’t dispose of it properly, if you don’t wash it, or if you don’t sanitize your hands after you touch it. Each of these are examples of a hole. And that’s in just one layer.

To be as safe as possible, and to keep those around you safe, it’s important to use more slices to prevent those volatile holes from aligning and letting virus through.

Q. What have we learned since March?

A. Distance is the most effective intervention; the virus doesn’t have legs, so if you are physically distant from people, you avoid direct contact and droplets. Then you have to consider inside spaces, which are especially in play during winter or in hotter countries during summer: the bus, the gym, the office, the bar or the restaurant. That’s because we know SARS-CoV-2 can remain infectious in aerosols (small floaty droplets) and we know that aerosol spread explains Covid-19 superspreading events. Try not to be in those spaces with others, but if you have to be, minimize your time there (work from home if you can) and wear a mask. Don’t go grocery shopping as often. Hold off on going out, parties, gatherings. You can do these things later.

We don’t talk about eye coverings much, but we should, because we don’t know enough about the role of eyes in transmission. We do know that eyes are a window to the upper respiratory tract.

Q. Where does the “misinformation mouse” fit in?

A. The misinformation mouse can erode any of those layers. People who are uncertain about an intervention may be swayed by a loud and confident-sounding voice proclaiming that a particular layer is ineffective. Usually, that voice is not an expert on the subject at all. When you look to the experts — usually to your local public health authorities or the World Health Organization — you’ll find reliable information.

An effect doesn’t have to be perfect to reduce your risk and the risk to those around you. We need to remember that we’re all part of a society, and if we each do our part, we can keep each other safer, which pays off for us as well.

Another example: We look both ways for oncoming traffic before crossing a road. This reduces our risk of being hit by a car but doesn’t reduce it to zero. A speeding car could still come out of nowhere. But if we also cross with the lights, and keep looking as we walk, and don’t stare at our phone, we drastically reduce our risk of being hit.

We’re already used to doing that. When we listen to the loud nonexperts who have no experience in protecting our health and safety, we are inviting them to have an impact in our lives. That’s not a risk we should take. We just need to get used to these new risk-reduction steps for today’s new risk — a respiratory virus pandemic, instead of a car.

Q. What is our individual responsibility?

A. We each need to do our part: stay apart from others, wear a mask when we can’t, think about our surroundings, for example. But we can also expect our leadership to be working to create the circumstances for us to be safe — like regulations about the air exchange inside public spaces, creating quarantine and isolation premises, communicating specifically with us (not just at us), limiting border travel, pushing us to keep getting our health checks, and providing mental health or financial support for those who suffer or can’t get paid while in a lockdown.

Q. How can we make the model stick?

A. We each use these approaches in everyday life. But for the pandemic, this all feels new and like a lot of extra work. Because everything is new. In the end, though, we’re just forming new habits. Like navigating our latest phone’s operating system or learning how to play that new console game I got for my birthday. It might take some time to get across it all, but it’s worthwhile. In working together to reduce the risk of infection, we can save lives and improve health.

And as a bonus, the multilayered risk reduction approach can even decrease the number of times we get the flu or a bad chest cold. Also, sometimes slices sit under a mandate — it’s important we also abide by those rules and do what the experts think we should. They’re looking out for our health.

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The Newest Hotel Amenity? Virus-Scrubbed Air

The Newest Hotel Amenity? Virus-Scrubbed Air

Hotels, and even some cruise ships, are installing state-of-the-art filtration systems that claim to tackle the coronavirus where it is believed to be the most dangerous: in the air.

Credit…Tom Grillo


  • Dec. 3, 2020, 5:00 a.m. ET

When the coronavirus first hit, hotels quickly adopted enhanced cleaning polices, including germ-killing electrostatic spraying and ultraviolet light exposure in guest rooms and public areas.

But as research on virus spread has shifted focus from surface contact to airborne transmission, some hotels and cruise ships are scrubbing the very air travelers breathe with a variety of air filtration and treatment systems.

“The best amenity that any hotel could provide under those circumstances is safety, especially in the air,” said Carlos Sarmiento, the general manager of the Hotel Paso del Norte in El Paso, Texas. The 1912 vintage hotel recently reopened after a four-year renovation that included installing a new air purification system called Plasma Air that emits charged ions intended to neutralize the virus and make particles easier to filter out.

With the new air-scrubbing campaigns, hotels are following airlines, many of which have hospital-grade, high-efficiency particulate air (HEPA) filters that are said to be over 99 percent effective in capturing tiny virus particles, including the coronavirus.

Hotels and cruise ships can more easily ensure social distancing than airplanes, but, given the recent research on the importance of enhanced air filtration, some are adding air-cleaning dimensions to their heating, ventilation and air conditioning (HVAC) systems, which already aim to remove dust, smoke, odors and allergens.

How air is purified

Researchers, including those at New Orleans’s Tulane University, have found that the tiny aerosol particles of SARS-CoV-2 that are emitted when someone with the virus speaks or breathes can remain in the air for up to 16 hours.

Along with social distancing, mask wearing is the first line of defense against breathing contaminated air indoors, said Dr. Philip M. Tierno Jr., a professor of microbiology and pathology at New York University School of Medicine, who has consulted with HVAC companies.

“HVAC systems are of great significance in reducing the amount of airborne particles since this virus can be spread in an airborne fashion,” he added, calling the tiniest aerosols “the most dangerous.”

There are several ways to remove these particles, he explained, including fresh-air ventilation, which dilutes the pathogens.

Air cleaning technologies include bipolar ionization systems, which, according to their manufacturers, send charged ions out on air currents that damage the surface of the virus and inactivate it. They may also bind with the virus aerosols, causing them to fall or be more easily filtered out.

However, some experts are skeptical, pointing to evidence that these systems may introduce ozone or particles that are dangerous if inhaled. ASHRAE, a professional society of air-conditioning, heating and refrigerating engineers, notes that the technology is still “emerging” and lacks “scientifically-rigorous, peer-reviewed studies.” The bipolar ionization company AtmosAir Solutions provided results of tests performed by the independent Microchem Laboratory, which evaluates sanitizing products, that found the technology reduced the presence of coronavirus by more than 99 percent within 30 minutes of exposure.

“We talk about it as nature’s cleaning device,” said Kevin Devlin, the chief executive of WellAir, which sells the bipolar ionization system Plasma Air installed at the Hotel Paso del Norte. He noted that air at high elevations in the mountains that “smells clean” has higher amounts of ions.

Some anti-viral HVAC systems feature germicidal ultraviolet light in the ductwork (the Federal Drug Administration states that ultraviolet-C lamps have been shown to inactivate the virus). Such a system was installed at The Distillery Inn in Carbondale, Colo., and includes a three-hour disinfection cycle between guests.

Systems often use a combination of these technologies with efficient air filters that remove contaminants. Filters with Minimum Efficiency Reporting Values (MERV) of 13 or higher are best at capturing the coronavirus, according to the Environmental Protection Agency.

According to its website, the agency “recommends increasing ventilation with outdoor air and air filtration as important components of a larger strategy that includes social distancing, wearing cloth face coverings or masks, surface cleaning and disinfecting, handwashing, and other precautions.”

“In a transient environment, like a hotel, motel or dormitory, you don’t know who was there before you and what their health was,” said Wes Davis, the director of technical services with the Air Conditioning Contractors of America, a trade association, adding that good housekeeping is a top priority in such places. “As for the other items like ultraviolet exposure or ionization, every little bit helps, but I’m not quite sure any of them is the perfect solution. It’s more like a concert.”

From property-wide to portable

Throughout the summer, the Madison Beach Hotel, part of Hilton’s Curio Collection of hotels, in Madison, Conn., used its outdoor spaces for dining and even holding meetings in tents. But with the approach of cold weather, HVAC contractors installed an air purification system that uses UV light and ionized hydrogen peroxide in most public areas of the hotel, including the indoor restaurant and meeting rooms. Spa treatment rooms each have their own portable air purification systems.

“We wanted to create an environment that was as safe as possible,” said John Mathers, the hotel’s general manager, adding that each guest room has its own closed HVAC system that doesn’t mingle with others and thus doesn’t require extra purifying. “The air being recirculated in your room is your air.”

But many hotels are bringing units into the guest rooms for extra assurance. In Rhode Island, rooms at the Weekapaug Inn and Ocean House hotel, both run by Ocean House Management, have Molekule air purifiers that destroy pollutants and viruses at a rate above 99 percent, according to the independent testing group Aerosol Research and Engineering Laboratories.

Larger units were recently added to restaurants and public spaces, and the portable units have become a top seller, starting at around $500, in Ocean House’s gift shop.

Decisions about installing air purification systems tend to happen at the property or ownership level, rather than the brand level. But Hilton has AtmosAir’s bipolar ionization air purification systems in its Five Feet to Fitness rooms, more than 100 guest rooms across 35 hotels that double as mini gyms with weights, indoor cycles and meditation chairs.

Many hotels have long offered allergy-free or wellness rooms to travelers that feature heightened purification systems. Pure Wellness has its Pure Room technology that claims to eliminate viruses, bacteria and fungi, including air filters effective enough to trap the coronavirus, in over 10,000 rooms worldwide.

Attempting to breathe easy on cruise ships

The 112-passenger SeaDream I from the SeaDream Yacht Club took many precautions — including pre-embarkation Covid-19 testing, electrostatic fogging of public areas and UV light sterilization after nightly turndown — before it launched its winter season from Barbados on Nov. 7, and still a passenger got the virus within days of departure, cutting the trip short. Eventually nine infections were diagnosed and the line canceled future 2020 sailings. (The cruse line did not respond to a requests for comment on whether any improvement had been made to the ship’s ventilation system.)

SeaDream’s failed cruise exemplifies the challenges the entire industry faces. Some health experts think that upgraded air filtration could help. Adopting systems that are “aimed at reducing occupant exposure to infectious droplets/aerosols,” and upgrading HVAC systems with MERV 13 filters were among 74 critical recommendations to ship lines made by the Healthy Sail Panel, a group of public health experts assembled by Royal Caribbean Group and Norwegian Cruise Line Holdings in September.

The Centers for Disease Control and Prevention maintains that ships remain vulnerable to spreading infection based on population density and the inability of crew in particular to maintain social distance in their work spaces and living quarters. Still, cruising is expected to resume in U.S. waters for ships carrying 250 or more passengers and crew in the first half of 2021, pending certification under the C.D.C.’s Framework for Conditional Sailing Order, which spells out minimum standards for social distancing, face coverings and hand hygiene, but does not mention air circulation systems.

Despite the C.D.C.’s lack of emphasis on air filtration, some cruise companies are upgrading their ventilation systems, in addition to designating quarantine areas and reconfiguring dining rooms.

Norwegian Cruise Line, for example, has announced its ships will use HEPA filters. And Princess Cruises has said it will upgrade its ships’ HVAC systems to MERV 13 filters, refresh the air in cabins and public spaces every five to six minutes, and install HEPA filters in areas such as medical centers and isolation rooms.

The new Virgin Voyages cruise line, whose launch has been delayed by the pandemic, confirmed it had installed AtmosAir bipolar ionization systems on its inaugural ship, the roughly 2,700-passenger Scarlet Lady, and a second ship coming in 2021.

This was a multimillion-dollar investment and based on our research and growing understanding of the virus, was an important step to sailing safely,” wrote Tom McAlpin, the chief executive of Virgin Voyages, in an email.

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Masks Offer Covid Protection, Provided You Wear Them Right

Is it time to upgrade your mask?

By now most of us have settled on a preferred cloth mask to protect ourselves and others from coronavirus. But new research shows that a few simple upgrades in fabric, filters and fit are likely to provide even more protection.

Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists, led the research, which tested 11 different mask materials. The findings confirmed what other labs have found: You don’t need a gold-standard N95 medical mask to stay safe from coronavirus. The right cloth mask, properly fitted, does a good job of filtering viral particles of the size most likely to cause infection.

But Dr. Marr and her colleagues found that small improvements to your mask can go a long way toward improving how well the mask protects you and others from potential infectious particles. They found that:

Three layers are better than two. The best mask has two tightly woven layers of outer material with a filter material sandwiched in the middle, Dr. Marr said. You can use surgical mask material or even a piece of a vacuum bag as a filter between two pieces of fabric. Coffee filters are an option, but can be less breathable. If you like your two-layer mask, you can just wear it over a surgical mask when you want added protection. A well-fitting fabric mask with a third filter layer can stop 74 to 90 percent of risky particles, the researchers found.

Flexible material is better. Stiff material creates gaps. Look for a mask made of tightly woven flexible material that contours to your face. Masks with wire that can be molded around the nose also fit better by closing gaps where air can escape out and seep in.

Ties are better than ear loops. Masks that tie around your head fit better and can be more comfortable. Ear loop masks can leave bigger gaps around your face and cause ears to become sore with longer use.

Face shields should be used with a mask. Face shields alone offered little to no protection. Although the clear plastic shield is impermeable, air seeps out and comes in around the edges of the shield. “It was the worst of everything,” said Jin Pan, a civil and environmental engineering Ph.D. student who was a co-author of the study. A face shield combined with a mask offers added protection, particularly for the eyes.

A well-fitted mask protects the wearer. Dr. Marr and her colleagues tested cloth masks for how well they protected others (outward protection) as well as the wearer (inward protection). Although masks are most efficient at filtering outgoing germs, they do stop incoming germs at nearly the same rate in most cases, the researchers found. Masks that did a poor job protecting the wearer were those made of stiffer materials and those worn loosely and with gaps around the edges.

A recent study from Denmark suggested that masks don’t protect the wearer, but Dr. Marr noted that in that study, many people weren’t using masks properly. “Fewer than half wore them as instructed,” Dr. Marr said. Although Dr. Marr’s findings come from a lab, rather than the real world, she said her group’s latest research should offer reassurance to people who wear well-fitted masks that they are getting additional protection from other people’s germs.

The research should also reassure people about the benefits of cloth masks, Dr. Marr said. She noted that masks can’t do “100 percent of the work,” and it’s important to combine mask wearing with other measures, like hand-washing and restricting social contacts.

“Something is better than nothing,” Dr. Marr said. “Even the simplest cloth mask of one layer of material blocks half or more of aerosols we think are important to transmission. If you go to a tighter weave and more layers, you’ll get even better performance.”

The Virginia Tech study was published online and has not yet been peer reviewed.

Masks Offer Covid Protection, Provided You Wear Them Right

Is it time to upgrade your mask?

By now most of us have settled on a preferred cloth mask to protect ourselves and others from coronavirus. But new research shows that a few simple upgrades in fabric, filters and fit are likely to provide even more protection.

Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists, led the research, which tested 11 different mask materials. The findings confirmed what other labs have found: You don’t need a gold-standard N95 medical mask to stay safe from coronavirus. The right cloth mask, properly fitted, does a good job of filtering viral particles of the size most likely to cause infection.

But Dr. Marr and her colleagues found that small improvements to your mask can go a long way toward improving how well the mask protects you and others from potential infectious particles. They found that:

Three layers are better than two. The best mask has two tightly woven layers of outer material with a filter material sandwiched in the middle, Dr. Marr said. You can use surgical mask material or even a piece of a vacuum bag as a filter between two pieces of fabric. Coffee filters are an option, but can be less breathable. If you like your two-layer mask, you can just wear it over a surgical mask when you want added protection. A well-fitting fabric mask with a third filter layer can stop 74 to 90 percent of risky particles, the researchers found.

Flexible material is better. Stiff material creates gaps. Look for a mask made of tightly woven flexible material that contours to your face. Masks with wire that can be molded around the nose also fit better by closing gaps where air can escape out and seep in.

Ties are better than ear loops. Masks that tie around your head fit better and can be more comfortable. Ear loop masks can leave bigger gaps around your face and cause ears to become sore with longer use.

Face shields should be used with a mask. Face shields alone offered little to no protection. Although the clear plastic shield is impermeable, air seeps out and comes in around the edges of the shield. “It was the worst of everything,” said Jin Pan, a civil and environmental engineering Ph.D. student who was a co-author of the study. A face shield combined with a mask offers added protection, particularly for the eyes.

A well-fitted mask protects the wearer. Dr. Marr and her colleagues tested cloth masks for how well they protected others (outward protection) as well as the wearer (inward protection). Although masks are most efficient at filtering outgoing germs, they do stop incoming germs at nearly the same rate in most cases, the researchers found. Masks that did a poor job protecting the wearer were those made of stiffer materials and those worn loosely and with gaps around the edges.

A recent study from Denmark suggested that masks don’t protect the wearer, but Dr. Marr noted that in that study, many people weren’t using masks properly. “Fewer than half wore them as instructed,” Dr. Marr said. Although Dr. Marr’s findings come from a lab, rather than the real world, she said her group’s latest research should offer reassurance to people who wear well-fitted masks that they are getting additional protection from other people’s germs.

The research should also reassure people about the benefits of cloth masks, Dr. Marr said. She noted that masks can’t do “100 percent of the work,” and it’s important to combine mask wearing with other measures, like hand-washing and restricting social contacts.

“Something is better than nothing,” Dr. Marr said. “Even the simplest cloth mask of one layer of material blocks half or more of aerosols we think are important to transmission. If you go to a tighter weave and more layers, you’ll get even better performance.”

The Virginia Tech study was published online and has not yet been peer reviewed.

Thumb Suckers and Nail Biters May Develop Fewer Allergies


Credit Getty Images

Babies have been seen sucking on their fingers in utero weeks before birth. But the sight of an older child with his fingers constantly in his mouth, sucking her thumb, biting his nails, can drive parents crazy, bringing up fears about everything from social stigma to germs.

A new study suggests that those habits in children ages 5 to 11 may indeed increase exposure to microbes, but that that may not be all bad.

When a pediatrician discusses thumb-sucking, it’s usually because a parent is worried. The thumb is in the mouth so constantly that there’s a worry about speech or about whether the teeth may be affected. It’s gone on too long, and an older child is being teased about it. And in those situations, especially when a child is over 4, we work with parents and children on how to break the habit.

Nail biting worries parents for similar reasons, and we often end up giving similar advice: Don’t make negative comments; look for the situations that bring on the behavior and find alternate strategies; praise and reward the child for not doing it; put a glove or a bandage on the hand to remind the child.

In a study published Monday in the journal Pediatrics, researchers drew evidence from an ongoing study of New Zealand children to show those whose parents described them as thumb-suckers and nail-biters were less likely to have positive allergic skin tests later in life.

The children were in the Dunedin Multidisciplinary Health and Development Study, in which 1,037 children born in 1972-73 in Dunedin, a coastal city in New Zealand, were assessed and tested as they grew up, with the most recent assessment done at age 38. Stephanie Lynch, a student at Dunedin School of Medicine and the first author of the paper, had the idea of using the data to look at a possible relationship between children who tend to have their fingers in their mouths and allergic sensitization.

The question of such a connection arose because of the so-called hygiene hypothesis, an idea originally formulated in 1989, that there may be a link between atopic disease — the revved-up action of the immune system responsible for eczema, asthma and allergy — and a lack of exposure to various microbes early in life. Some exposure to germs, the argument goes, may help program a child’s immune system to fight disease, rather than develop allergies.

In the study, parents were asked about their children’s nail-biting and thumb-sucking habits when the children were 5, 7, 9 and 11 years old. Skin testing for allergic sensitization to a range of common allergens including dust mites, grass, cats, dogs, horses and common molds was done when the children were 13 years old, and then later when they were 32. Thirty-one percent of the children were described as “frequent” nail biters or thumb suckers (or both) at one or more of those ages.

The study found that children who frequently sucked a thumb or bit their nails were significantly less likely to have positive allergic skin tests both at 13 and again at 32. Children with both habits were even less likely to have a positive skin test than those with only one of the habits.

These differences could not be explained by other factors that are associated with allergic risk. The researchers controlled for pets, parents with allergies, breast-feeding, socioeconomic status and more. But though the former thumb-suckers and nail-biters were less likely to show allergic sensitization, there was no significant difference in their likelihood of having asthma or hay fever.

Robert J. Hancox, one of the authors of the study, is an associate professor in the Department of Preventive and Social Medicine at Dunedin School of Medicine, a department that is particularly oriented toward the study of diseases’ causes and risk factors. He said in an email, “The hygiene hypothesis is interesting because it suggests that lifestyle factors may be responsible for the rise in allergic diseases in recent decades. Obviously hygiene has very many benefits, but perhaps this is a downside. The hygiene hypothesis is still unproven and controversial, but this is another piece of evidence that it could be true.”

Malcolm Sears, one of the authors of the paper, a professor of medicine at McMaster University in Hamilton, Ontario, who was the original leader for the asthma allergy component of the New Zealand study, said, “Early exposure in many areas is looking as if it’s more protective than hazardous, and I think we’ve just added one more interesting piece to that information.”

Dr. Hancox pointed out that the study does not show any mechanism to account for the association. “Even if we assume that the protective effect is due to exposure to microbial organisms, we don’t know which organisms are beneficial or how they actually influence immune function in this way.”

Thumb sucking, especially in an older child, can still be a problem if it interferes with the teeth, or causes infections on the fingers, or gets a child teased. Lynn Davidson, a developmental pediatrician who is an attending physician at the Children’s Hospital at Montefiore in the Bronx, and the author of a review article on thumb sucking, said she tends to be “very low-key” about thumb sucking, since children often stop on their own as they grow.

With older children, Dr. Davidson suggests that parents, if they are worried, should try to analyze when and why the child resorts to thumb sucking or nail biting, and then try behavioral techniques, like offering a child a foam ball to hold and squeeze at those moments. “In an older child you can use their input, ask, what would you do with your hands instead of putting them in your mouth,” she said.

Dr. Sears said, “My excitement is not so much that sucking your thumb is good as that it shows the power of a longitudinal study.” (A longitudinal study is one that gathers data from the same subjects repeatedly over a period of time.) And in fact, as researchers tease out the complex ramifications of childhood exposures, it’s intriguing to look at long-term associations between childhood behavior and adult immune function, by watching what happens over decades.

So perhaps the results of this study help us look at these habits with slightly different eyes, as pieces of a complicated lifelong relationship between children and the environments they sample as they grow, which shape their health and their physiology in lasting ways.

Picking Up an Infection in the Hospital


Credit Stuart Bradford

When the emergency room doctor pulled the blanket aside, looked at my elephant-size inflamed leg and said, “Whoa!” I knew that wasn’t a good sign.

Nor was the reaction of the emergency room nurse, who glanced down at my bizarrely swollen extremity, then started nervously backing away.

Health care practitioners are trained not to show their feelings, but there are clearly times when things look so bad that even they can’t hide their reactions.

I was in the emergency room at Los Robles Hospital in Thousand Oaks, Calif., because a few days earlier I had undergone what was supposed to be a relatively straightforward outpatient procedure to remove a skin growth on my leg. A couple of days after the surgery I felt fine. The surgeon told me I could drive whenever I was up for it, so we took our grandchildren to the Magic Castle in Hollywood. Running from room to room to see the different sleight-of-hand acts, I no longer felt fine. Now I felt a searing knife-like pain in my leg, which soon began to swell in size.

I went back to see my surgeon, who looked a little concerned. You have an infection, she said. Take these two antibiotic pills, schedule a Doppler scan for the next day, and all should be well.

That night, my leg got even bigger; from the waist down one side of me looked like I weighed 350 pounds (I’m not even half that.) My wife and I spoke to the surgeon, who was vague. “You could go to the E.R. if you want,” she said. “Or wait.”

I went and was admitted immediately. That night, a Doppler study showed no life-threatening blood clots. With no beds available, I was kept in the emergency department overnight, taking catnaps while trying to blot out the screams and moans from down the hall, before being given a room, and intravenous antibiotics, the next morning.

“This is very serious,” said Dr. Barry Statner, the infectious disease specialist who came to see me the next day in my hospital room. “We’ll cure you,” he said while firing questions at me about my medical history. “But you need to know, this is very serious.” I wondered if I was going to lose my leg.

For the first time in my life, I had entered the world of the powerless sick. Like most people, I had long heard about the dangers of contracting infections in hospitals or surgical centers, but I never took them seriously. I assumed that, except for the worst cases, such as those caused by improperly disinfected scopes and other instruments, they were little more than a minor annoyance.

In fact, infections kill, and they do so regularly, even to people who are otherwise healthy.

“There are diseases that can take a regular healthy person and destroy them within hours,” Dr. Statner told me. “You don’t get a second chance. People don’t realize how rapid and lethal infections can be.”

In the United States in 2014, one in 25 patients contracted a hospital-borne infection on any given day, according to the Centers for Disease Control and Prevention. Some 722,000 Americans developed such infections in hospitals in 2011, and about 75,000 died during their hospital stay.

I count myself as somewhat lucky. My wound was infected with a relatively run-of-the-mill strain of Staphylococcus aureus, and after a week in the hospital, followed by two weeks hobbling around the house, where a nurse visited daily to pack my wound with prodigious amounts of gauze, I was on the road to recovery. I was fortunate it wasn’t one of the more serious infections that lurk around hospitals, like MRSA, a “super bug” strain of Staph that is resistant to most antibiotics, or C. difficile, which can cause months of relapsing and severe diarrhea.

No one knows how my infection happened. It was the first, and only, case of this type of infection at the surgical center that year, I was told by Dr. Richard Hoberman, the medical director and the anesthesiologist who had put me under general sedation during my surgery. Clearly shaken by what happened to me, he unexpectedly popped in to my hospital room early in my stay to apologize.

My infection resulted in my being “the subject of several very uncomfortable meetings with the hospital administration” and a five-page written report, Dr. Hoberman said. (They passed on sharing a copy of that report with me.)

Hospitals are anxious to reduce hospital-borne infections, to reduce deaths and improve their reputations. There are also immediate financial incentives: Medicare may penalize hospitals for infections acquired in the facility.

The medical center I’d gone to for my surgery, associated with Los Robles Hospital, practices all the well-known standard forms of infection prevention: constant washing of hands; sterilizing equipment; giving patients preoperative antibiotics; cleaning operating room surfaces and thorough cleaning at night. In addition doctors are not allowed to enter the operating room wearing the same scrubs they wear in the street. To prevent the spread of microbes, cellphones and jewelry are banned, as well as ties.

But infections still happen. While most infections happen at the time of surgery, according to Dr. Statner, they can occur in the hospital room as well. A break in the skin, a lapse in the handling of a paper surgical cover, lackluster cleaning, intravenous lines or catheters that remain in too long — all can result in infection.

In the end, stamping out infections depends on the vagaries of human behavior. “Medical care is done by people. There can be gaps in quality. People must remember to do certain things,” said Dr. Arjun Srinivasan, the associate director for health care associated infection prevention programs at the C.D.C.

“Far too many Americans get sick in the hospital,” said Dr. Thomas R. Frieden, director of the C.D.C. “The importance of making care safer cannot be overstated.” One limitation is that the C.D.C. can only recommend, not mandate, practices to reduce infection, he said. And because hospitals are owned by various corporations, it can be a challenge to know how effectively patients are being protected in any one hospital. If a patient is moved from one hospital to another across town, he said, it “can cause problems,” given that one hospital may have less rigorous infection-reduction policies than another.

Hospitals are experimenting with new disinfection techniques. For example, some disinfecting machines using ultraviolet light are so powerful that no one is allowed in the room when they are in operation. And routine measures like thorough hand washing, and having patients thoroughly shower using chlorhexidine before surgery is helping bring infection rates down in the United States in recent years. In the three to six years before 2014, depending on the type of infection, the rate of surgical-site infections has dropped by 17 percent, C. diff by 8 percent and hospital-borne MRSA by 13 percent, according to the C.D.C. However, there was no change in the rate of urinary tract infections caused by catheters between 2009 and 2014.

Infection rates have dropped even more steeply in Britain, where total MRSA reduction from 2004 is now 80 percent, according to Dr. Mark Wilcox, the head of medical microbiology at Leeds Teaching Hospitals and the head of the C. difficile task force for Public Health England. Leeds Hospital used to see 15 to 25 MRSA infections per month; now it gets five per year, he said.

Dr. Wilcox attributes their success in part to having a coordinated, single health system for the entire country. To encourage hygiene, National Health Service hospitals post current infection rates on boards that can be seen by doctors, patients and visitors. Hospitals are “obsessional” about hand hygiene, Dr. Wilcox said. To do the best cleaning job, health workers must be “bare below the elbows,” with no watches on the wrist. Lab coats, while making a doctor look professional, are also banned, as they can brush up against patients and transfer bacteria from one patient to the next.

Hospitals that fail to meet infection reduction targets are visited by a “hit squad improvement team” that demands a new plan, Dr. Wilcox said. Those that fail lose the right to decide how to spend some of their annual budget.

“A decade ago, people would say that only a small proportion of infections are preventable,” said the C.D.C.’s Dr. Srinivasan. “Now we know that a large proportion are preventable. We’ve turned that paradigm on its head.”

Staying Healthy While Traveling the Globe


Credit Paul Rogers

On a recent trip to Tanzania with four grandsons, my most important task (beside protecting them from the jaws of a lion or leopard) was to keep them, and myself, in good health. It would not have been much fun to be stuck in a tent next to the commode or flattened on a cot while the rest of the gang viewed a dazzling array of wild animals from the safety of a Land Rover.

Although I came prepared for the worst, I did everything I could to make our trip the best. And I’m happy to report, no one got sick and we all had a great time.

When I described the steps I took to friends and physicians, they urged me to write about them. So here goes, along with a host of other helpful travel hints from well-informed professional sources.

No. 1: I reminded my grandsons daily, any water you drink or use to brush your teeth must come from a sealed bottle that you open. Ice wasn’t an issue in the bush, but that too should be prepared from bottled water. When you take a shower or swim in a pool, keep your mouth shut. (This warning was particularly pertinent for one grandson who always sings in the shower.)

No. 2: Before every meal, we each chewed one pink tablet of bismuth subsalicylate (sold as Pepto-Bismol and various store brands).

I have used this preventive since first reading about it in 1980 in The Journal of the American Medical Association in a study led by Dr. Herbert L. DuPont, an infectious disease and travel medicine specialist at the University of Texas, Houston. The study described how using these tablets greatly reduced the risk of traveler’s diarrhea among American students traveling to Mexico. In a subsequent study published in 1987, Dr. DuPont and colleagues reported that two tablets chewed four times a day reduced the risk of developing diarrhea by 65 percent. (Each tablet contained the standard dose, 262 milligrams of bismuth subsalicylate.)

I have relied on these tablets, albeit in a lesser dose because I’m a lot smaller than average, during trips to Vietnam, Thailand, Peru, Indonesia, India and Nepal, and never got sick despite eating salads and peeled fruit, which one is warned to avoid. In fact, in India and Nepal, my traveling companion, who also took the tablets, and I were the only ones who stayed healthy even though the others in our group assiduously avoided those no-no foods and we did not.

So for the five of us going to Tanzania, I packed 15 tablets for each day of our trip — and no one experienced the slightest gastrointestinal upset. That wasn’t the case, though, for most of the others on our itinerary. However, if you choose to try this preventive, I suggest you check first with your doctor and perhaps consider using Dr. DuPont’s larger dosage.

Without a preventive, which is no guarantee against food-borne illness, stick to “safe food” that is cooked and served hot, and fruits and vegetables you have washed in bottled water and peeled yourself. Never eat undercooked foods — eggs, meat, fish or poultry — or any food sold by street vendors.

Reduce your exposure to germs by washing your hands often, and always before eating. A hand sanitizer with at least 60 percent alcohol can be used if soap and water are unavailable.

I took no chances, especially since I was responsible for four children. I had an emergency supply of Lomotil (for digestive problems) and azithromycin (Zithromax Z-pak, for infections) just in case.

No. 3 (really No. 1 chronologically): I made sure we were all up-to-date on routine vaccines — measles-mumps-rubella, varicella (chickenpox), diphtheria-tetanus-pertussis, polio and an annual flu shot — and added two (for hepatitis A and typhoid) that the Centers for Disease Control and Prevention recommends for travelers to Tanzania. You can review recommendations for other destinations on the C.D.C. website at cdc.gov/travel. We also each filled prescriptions for generic Malarone (atovaquone proguanil) to prevent malaria, and I checked daily to be sure the boys remembered to take it.

I also packed an ample supply of sunscreen, insect repellent with 20 percent or more of DEET, and a first-aid kit of hydrocortisone cream, antibiotic ointment and a variety of bandages, though happily the latter two were never needed. For one grandson prone to motion sickness, I took some meclizine as well.

As the oldest traveler in the group (and the shortest now that my youngest grandson, at age 11, has passed me), I am acutely aware of the risk of blood clots when flying long distances. I always book an aisle seat so I can get up every hour or so and walk around for a minute. It also helps to move your legs and flex your ankles frequently. You might also wear graduated compression stockings on very long trips. Similar precautions apply to long car or train trips.

Although the risk of clots is generally very small, they can be life-threatening. At greatest risk are people over 40, those who are obese or pregnant or have limited mobility (for example, because of a leg cast) or who have a personal or family history of clots. Estrogen-containing medications also raise the risk; I usually take one of those, raloxifene, prescribed to protect my bones. But it can increase the risk of a clot, so I stop taking three days before a plane trip of four or more hours. For more information, check the C.D.C. advisory on blood clots and travel, and talk to your doctor.

Even when traveling alone, I always purchase travel health and medical evacuation insurance because, well, you never know. People on my various trips have broken bones or become seriously ill and had to return home mid-trip. Two men died while snorkeling on separate trips of mine.

Consider carrying a card that lists your blood type, any chronic illnesses or serious allergies and the generic names of prescription medicines you take. Bring some extra doses in case of travel delays.

Other worthy precautions: To avoid nasty parasitic diseases like schistosomiasis, do not swim or wade in fresh water in developing countries or wherever the sanitation is poor. Pools should be chlorinated. However adorable an animal (domestic or wild) may be, keep your distance. Do not touch or feed any animal you don’t know. Some carry rabies. Should you get bitten or scratched by an animal, wash the wound immediately with soap and clean water and, if at all possible, get to a doctor quickly.

If you expect to be at a high altitude (8,000 feet or higher), consult your doctor about medicine to prevent altitude sickness, which can take more than the starch out of a person. I was glad I did when traveling to Cusco, Peru (11,154 feet) and climbing in the Sacred Valley of the Incas (9,000 feet). The recommended preventive is acetazolamide (generic version of Diamox).

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