The Ultimate Step-by-Step Guide to Making Decisions in a Pandemic
By: Kristi Mcclamroch, Phd
Tags: Life, Covid 19, Epidemiology, Pandemic, Coronavirus

The Ultimate Step-by-Step Guide to Making Decisions in a Pandemic

A framework from two epidemiologists

People enjoy the beach amid the coronavirus pandemic in Huntington Beach, California on April 25, 2020. Photo: APU GOMES/Getty Images

Co-authored by JoLynn Montgomery, PhD, MPH

In many communities in the United States, government restrictions designed to curtail the spread of Covid-19 are being lifted, despite rising rates of infection. Many of the messages to the public about how seriously to take Covid-19 and how to stay safe are confusing. Some people are returning to their activities as if the pandemic is over, while others are avoiding in-person interactions. How can you make sense of it all and figure out how and when to safely proceed with your life?

Recently, several visual guides have been circulating on social media in an attempt to provide some instruction. These images show various in-person activities ranked from low risk to high risk. Unfortunately, these rankings are of limited use because they don’t address the specific circumstances of the activities that might make them risky. Furthermore, the rankings don’t provide any guidance about how to reduce your risk while doing these activities.

For example, in one ranking, “going to the beach” is listed as a moderate risk activity. But going to the beach is not always risky. The level of risk is directly related to how crowded the beach is. The more crowded, the more risky. It is misleading to rank all beach outings as moderate risk. What might really help is some guidance about how to have a safer beach outing.

These rankings are just one example of information about Covid-19 that is leaving many of us overwhelmed and unsure of what to do. What we need are tools we can use to make decisions about participating in specific activities and reducing the risk of catching or spreading Covid-19.

“Risk reduction” is the idea that a person can change or skip specific activities in order to lower their risk of infection. This is different from “risk elimination,” which is the idea of completely avoiding all in-person activities to remove any risk. The task of eliminating all in-person activities is difficult in the short term and nearly impossible in the long term. Experts predict that Covid-19 will be part of our lives for the foreseeable future, so risk reduction is a more realistic long-term approach.

This framework will empower you to make informed choices about your daily life during the Covid-19 pandemic just like the experts do.

A recent article in the Washington Post presented information about how each of six health experts (including Dr. Fauci himself) apply risk reduction to their daily activities in order to more safely interact with others. Although their approaches depend on their personal and local circumstances, they all used the process of critical thinking to reduce their risk of Covid-19.

We are two infectious disease epidemiologists who are currently writing a book about how people can use critical thinking skills to better understand health information. Since the beginning of the pandemic, we have been working to effectively communicate uncensored information about Covid-19 to the public. We have developed a 5-step framework, based on the critical thinking process, that everyone can use. This framework will empower you to make informed choices about your daily life during the Covid-19 pandemic just like the experts do.

One quick caveat of importance: It is critical to note that anyone who has Covid-19 should not participate in any in-person activities until their health care provider says it is safe to do so. This population includes:

People who have been diagnosed with Covid-19

People who have recently been told that they are infected with the virus that causes Covid-19, whether or not they have symptoms

People who have symptoms, whether or not they have been tested for Covid-19

People who have been exposed to someone with Covid-19 and have been advised by local public health officials and/or a physician to quarantine themselves for a specific period of time.

The 5-Step Framework

This framework is intended to be used for one activity at a time. It will lead you through a series of questions so that you can assess the following:

the risk that Covid-19 will spread during the activity

the negative consequences of Covid-19 to you and others

the importance of the activity to you

Ideally, this process will enable you to prioritize your choices and activities during this long-term pandemic. Finally, the framework will help you identify adjustments to make a given activity less risky.

Step 1: Identify an activity that involves in-person interaction.

Step 2: Assess the risk that Covid-19 will spread during this activity.

Step 3: Assess the negative consequences of Covid-19 transmission for you and the people around you.

Step 4: Weigh the importance of participating in the activity against the risks and negative consequences.

Step 5: If you decide to go ahead with the activity, identify adjustments that will reduce your Covid-19 risk.

Step 1: Identify an activity that involves in-person interaction

You can choose to focus on an in-person activity that you are currently doing, or you can choose an activity that you aren’t doing because of the pandemic, but that you want to resume.

Examples include:

Going to work in-person

Traveling by airplane

Staying overnight in a hotel

Using public transportation

Eating in a restaurant

Getting together with friends

Seeking social services

Allowing children to get together with friends

Sending children to daycare, school, or college

Attending a religious service

Going to a bar or nightclub

Visiting an elderly relative

Attending a live event

Going to a salon or barbershop

Hugging, kissing, or shaking hands

Exercising at a gym

Going to a non-urgent medical or dental appointment

Attending a wedding or funeral

Remember that the framework is intended to be used for one activity at a time.

Step 2: Assess the risk that Covid-19 will spread during the activity

In general, risk refers to how likely something is to happen. Risk that Covid-19 will spread depends on whether or not an uninfected person will come into contact with the virus during the activity.

Remember that Covid-19 is spread when virus particles in the mucus or saliva from a person with Covid-19 enter the mouth, eyes, nose, or lungs of a person without Covid-19. To do this, the virus particles have to successfully travel from one person to another.

Questions to help you make this assessment:

1. How many people are involved in the activity?

The more people involved in the activity, the more likely it is that at least one is infected with Covid-19. If one person is infected, there is a risk that Covid-19 will spread.

2. How close are people to each other during the activity? Will it be crowded?

The smaller the distance between people during the activity, the more likely it is that Covid-19 can spread from one person to another.

3. How long does the activity last?

The longer the activity lasts, the more likely it is for Covid-19 to spread from one person to another.

4. Does the activity occur indoors or outdoors?

Covid-19 is more likely to spread during an activity that takes place indoors.

5. Does the activity involve people exhaling forcefully?

During certain activities, people exhale more forcefully than usual, for example when they are yelling, singing, coughing, or exercising. The harder you exhale, the farther virus particles are able to travel, which increases the risk that Covid-19 will spread.

6. Does the activity involve touching shared surfaces or objects?

When someone with Covid-19 exhales, heavy droplets that contain the virus fall to the ground or other surfaces. The virus can live on surfaces for hours or days, depending on the type of surface. For a person to become infected by a contaminated surface, they have to touch that surface with their hands and then rub their eyes, nose, or mouth. Generally, handwashing solves this problem.

7. Are any of the activity participants, including you, infected with Covid-19?

Anyone might have Covid-19, even if they don’t have any symptoms. Some people are at higher risk than others if they regularly come into contact with people who have Covid-19.

For example, health care workers may be at higher risk because they regularly see patients who are infected with Covid-19. Some people may be at higher risk because they spend a lot of time in crowded places. Some people may be at lower risk because they have spent very little time around other people.

The only way to be certain about a person’s infection status is for that person to have been very recently tested. Unfortunately, most people don’t know if they are infected because they haven’t had a recent test.

County-level information gives a much better sense of active transmission in a community than state-level information.

8. Is the activity taking place in a community where Covid-19 is spreading?

The Covid-19 infection status of every person involved in an activity is often unknown, but the number of new cases in the community can provide a sense of whether Covid-19 is actively spreading.

There are many sources of information about the amount of Covid-19 in different geographic areas. However, these sources do not always provide the information needed to answer this question. We recommend the “Pandemics Explained” website from the Harvard Global Health Institute, which shows the daily number of new cases per 100,000 people for each county in the United States.

County-level information gives a much better sense of active transmission in a community than state-level information. When using the website, we always make sure the ‘counties’ button is selected so that we can see information for the county we’re curious about. Each county is color-coded, representing the level of Covid-19 spread. Green indicates the lowest level of transmission, followed by yellow, orange, and then red, which indicates the highest level of transmission. The greater the level of spread in an activity participant’s county, the more likely it is that they are infected with Covid-19.

We don’t work with the creators of the site, but we find this site to contain the most accessible source of relevant information. If you are in a country other than the United States, you will need to find a different source of local-level information.

9. Does the activity take place in a community in which there is an effective Covid-19 vaccine available?

As of early July 2020, an effective vaccine has not yet been developed. Remember that when an effective vaccine does become widely available, it will reduce people’s risk of infection, but it won’t eliminate all transmission.

Step 3: Assess the negative consequences of Covid-19 transmission for you and the people around you

One of the negative consequences of Covid-19 transmission is the development of severe disease, which can lead to death. Another consequence is that one person’s severe disease impacts the lives of the people around them. A third consequence is that one person infected with Covid-19 can spread the virus to many people, and each of these people can spread it to many more.

Questions to help you make this assessment:

1. What is your risk for severe Covid-19?

If infected, everyone is at risk for severe Covid-19 or death. Older people and people with certain underlying medical conditions are even more likely to get very sick or die. Check with your medical provider to get more information about your personal risk of severe Covid-19.

2. What is the risk for severe Covid-19 of the other activity participants?

You may not know the risk for severe Covid-19 of the other participants. If you don’t have this information, you should assume that Covid-19 could have severe health consequences for them.

3. If you get infected, who might you infect? Are they at high risk for severe disease?

Think about the people with whom you spend time. Any of these people could be infected by you. Some of them might be at greater risk for severe disease than others.

4. If you take care of other people and you get sick, who will take care of them?

You might be responsible for people who cannot take care of themselves — children, elderly individuals, and people with disabilities. If you get sick with Covid-19, you might not be able to continue to care for your dependents. That could result in serious consequences for them.

5. If you get sick, who will take care of you?

You might have a spouse, friend, adult child, or parent who can take care of you, but caring for you would be a burden on them. If you don’t have someone to take care of you, the strain of being sick may become more serious for you.

6. Is the medical system in your community able to handle additional cases of Covid-19? Or is it already overwhelmed?

People who get very sick from Covid-19 require medical attention. Doctors, nurses, and hospitals are easily overwhelmed when there are many cases of Covid-19. If medical care is limited due to an overwhelmed system, you and the people around you might not be able to get the care you need.

7. Are effective treatments for Covid-19 currently available?

As of July 2020, there aren’t enough effective treatment options available for people who have Covid-19. Remember that even when effective treatments are more widely available, some people will still experience severe disease.

Step 4: Weigh the importance of participating in the activity against the risks and negative consequences

Participating in an activity may initially feel very important to you. However, it is the overall relative importance of this activity, considering both the risk of Covid-19 spread and the negative consequences, that should determine how you will proceed.

Questions to help you make this assessment:

1. Why do you need to do the activity?

Different activities meet different needs. For example, you might participate in an activity to obtain money, food, health care, or housing. You might participate in an activity to develop or maintain personal connections, to have physical contact, or to express yourself and your beliefs. Your specific needs depend on your personal circumstances.

2. Can you simplify the activity?

Identify the component of the activity that meets your needs. If possible, simplify the activity to focus on these important components.

3. How urgent is the activity?

Some activities are more urgent than others and some are urgent because they can only happen right now. Your sense of urgency may increase the activity’s importance to you.

4. What is the relative importance of the activity?

Consider whether the activity is still important to you, even after you weigh importance against risks and consequences. For some people, activities with any risk of Covid-19 transmission and/or any negative consequences will have lower relative importance.

5. Do you plan to go ahead with the activity?

Now it is time to decide whether or not you will participate in the activity.

If you decide that the RISK IS TOO HIGH, then you should NOT DO THE ACTIVITY.

If you decide that there are TOO MANY NEGATIVE CONSEQUENCES, then you should NOT DO THE ACTIVITY.

If you decide that the activity is NO LONGER IMPORTANT, then you should NOT DO THE ACTIVITY.

If you DECIDE TO GO AHEAD WITH THE ACTIVITY, then you should IDENTIFY ADJUSTMENTS that will make it safer.

Step 5: If you decide to go ahead with the activity, identify adjustments that will reduce your Covid-19 risk

Here’s where you get creative! There are many adjustments that can make activities safer from Covid-19.

Some adjustments involve changing something about the activity itself. These types of adjustments work well when you have enough control over the activity to change it. Other adjustments involve changing your behavior during the activity.

It is important to identify adjustments that will allow the activity to still meet your needs. Some adjustments may be easier to incorporate than others, and some may have a bigger impact on risk than others. The best approach is to consider all adjustments.

Remember that, even with adjustments, there is still some risk that Covid-19 will spread when you choose to pursue a social activity.

Let’s look at some sample adjustments for specific activities.

The activity lasts for more than a few minutes

Activity adjustment: Shorten the amount of time the activity lasts

Behavior adjustment: Limit the amount of time you spend participating in the activity

The activity involves more than one other person

Activity adjustment: Reduce the number of people participating in the activity at the same time; reschedule the activity to a time when there are fewer participants

Behavior adjustments: Reduce the number of people with whom you come into contact during the activity

The activity puts people in close proximity to each other

Activity adjustments: Space people farther apart; move the activity to a larger venue; install a physical barrier between people; reschedule the activity to a time when the venue is less crowded

Behavior adjustments: Take a few steps back to increase the distance between you and others; wear a mask or face shield to provide a protective barrier between you and others; go to an alternate venue where other people are making the same adjustments you are

The activity takes place indoors

Activity adjustment: Relocate the activity outdoors

Behavior adjustments: Open windows and doors; wear a mask or face shield to provide a protective barrier between you and others

The activity involves people exhaling forcefully

Activity adjustments: Space people farther apart; move the activity outdoors; move the activity to a larger venue

Behavior adjustment: Take a few steps back to increase the distance between you and others

The activity involves surfaces and objects that are touched by multiple people

Activity adjustment: Minimize the use of shared surfaces and objects

Behavior adjustments: Avoid touching shared surfaces and objects; decontaminate shared surfaces and objects; wash your hands

These adjustments apply to almost all activities:

Stay home if you are sick

Advocate for your safety by asking others around you to make adjustments to the activity as well

Call your state, local, and other relevant government officials to advocate for testing

Ask activity organizers for information about adjustments being made

Wash or sanitize your hands often

Cover coughs and sneezes

Minimize touching your face around others

Get a Covid-19 test to know your status

Some activities can easily be done over phone or video. And you can always delay certain activities. For ongoing activities, you can also choose to participate less often.

For handwashing to be an effective adjustment, you must use proper handwashing techniques:

Wet your hands with clean, running water

Lather your hands with soap

Scrub your hands with the soap for at least 20 seconds

Rinse your hands well under clean, running water

Air-dry your hands or dry them with a clean towel

For wearing a mask to be an effective adjustment, you must use proper mask wearing techniques:

Wash your hands before and after touching your mask

Touch only the bands or ties when putting on and taking off your mask

Make sure the mask fits to cover your nose, mouth, and chin during the activity. If you adjust the mask to cover those areas, wash your hands before and after

Make sure you can breathe and talk comfortably through your mask

Wash reusable masks after each use. Discard disposable masks when they are visibly soiled or damaged

Adjusting Real-Life Situations

What do these adjustments really look like?

Let’s go back to the examples of in-person activities suggested in Step 1. For each activity, imagine that you have worked through the framework and decided to go ahead with it. Here are some adjustments to consider for each activity. Please note that we have not listed all possible adjustments, and remember that not all adjustments make sense for all personal circumstances.

Going to work in-person

Maintain a distance of at least 6 feet from others

Avoid socializing closely with people during breaks

Spend your breaks outdoors

Wear a mask

Install, or ask your employer to install, a plexiglas shield between you and others

Stay home if you are sick

Traveling by airplane

Choose an airline that limits airplane capacity

Choose a flight with open seats remaining

Choose an airline that is requiring customers to wear masks

Wear a mask

Limit eating and drinking during the flight so that you don’t have to remove your mask

Don’t interact with other people on the airplane

Wash or sanitize your hands regularly

Instead of flying, drive and minimize stops

Stay home if you are sick

Staying overnight in a hotel

Minimize the number of nights you stay

Don’t spend time in the lobby when there are lots of other people around

Use the least busy entrance to the hotel

Maintain a distance of at least 6 feet from others

Choose a hotel where the staff is wearing masks

Wear a mask when around other people

Forgo the daily cleaning service

Taking the bus

Take a less busy bus route

Stand or sit away from others

Wear a mask

Wash your hands when you get off of the bus

Walk or ride your bike instead

Eating in a restaurant

Skip dessert and coffee to shorten your stay

Limit the number of people at your table

Choose a restaurant where tables are spaced far apart

Go to the restaurant at a time when it is less crowded

Choose a restaurant where you will be able to eat outdoors

Wait outdoors for your table to be ready

Wear a mask when you aren’t eating or drinking

Choose a restaurant where servers are wearing masks

Order your food to go

Going to a coffee shop

Limit the amount of time you stay

Go to the coffee shop when it is less crowded

Wear a mask when you aren’t eating or drinking

Order your coffee to go

Choose a coffee shop where you can use the drive-through window

Getting together with friends

Limit the amount of time you spend

Limit the number of friends

Maintain a distance of at least 6 feet from others

Get together outdoors

Wear a mask

Socialize with friends who are making the same adjustments as you

Going to a social services office

Go when it is less crowded

Stand as far away from others as possible

Wear a mask

Make an appointment so you don’t have to wait as long

Allowing your child to play with friends

Limit the amount of time children are together

Limit the number of friends included

Encourage play that involves distance between children

Have the children play outdoors

Require your child to wear a mask

Encourage play that minimizes touching shared surfaces and objects

Encourage your child to play with friends who are making the same adjustments

Sending your child to school

Encourage your child to put space between themselves and others

Give your child a mask to wear and explain proper mask wearing techniques

Explain proper handwashing techniques and encourage your child to wash or sanitize their hands often

Encourage your child to cover coughs and sneezes when they are not wearing a mask

Encourage your child to minimize touching their face at school

Ensure that your child has back-up masks, tissues, and hand sanitizer

Educate yourself and your child about the adjustments the school is making or requiring

Call your school superintendent and your state and local government officials to advocate for testing all school staff and students

Do not send your child to school if they are sick

Attending a religious service

Attend a shorter service

Attend small religious study groups instead of large services

Go to a less crowded service

Connect with others in small groups

Go to a service outdoors

Go to a service where others are wearing masks

Wear a mask

Attend a service online

Going to a bar

Limit the amount of time you stay

Keep some distance between you and others

Choose a bar that is less crowded

Choose a bar where others are wearing masks

Sit in the outdoor area of a bar

Wear a mask

Ask the bartender to turn down the music so people don’t have to yell

Ask about the sanitization process for drinking glasses; if inadequate, drink from a bottle

Wash your hands after you leave the bar

Get tested for Covid-19

Wait until a later date to return

Visiting an elderly relative

Limit the length of the visit

Keep some distance between you and your relative

Visit from outdoors while your relative is indoors

Wear a mask

Give a mask to your relative

Have the visit by video call

Wave hello and goodbye instead of hugging or kissing them

Attending a sporting event

Choose an event where you can sit farther away from others

Stay as far away from others as possible

Choose a sporting event that is held outdoors

Wear a mask

Limit yelling

Going to a salon for a haircut

Maintain a distance of at least 6 feet from other customers

Go at a time when it is less crowded

Wait outdoors for the previous client to finish

Wear a mask

Choose a salon where the hairdresser is wearing a mask

Make your appointment shorter by washing your hair before you go and drying it yourself at home

Shaking hands

Wave or bow instead

Use words instead

Exercising at a gym

Limit the amount of time you stay

Choose a gym where people are staying more than 6 feet apart from each other

Stay more than 6 feet apart from others

Exercise outdoors

Choose a gym where the windows are open

Choose a gym where people are wearing masks

Wear a mask

Disinfect the weights and machines before and after you use them

Wash your hands when you are done exercising

Going for a dental cleaning

Wait in the car instead of the waiting room

Brush your teeth at home instead of when you get there

Call ahead to see what safety protocols the office is implementing

Attending a funeral

Allow only a small group at the burial

Limit the number of people you hug

Keep distance between you and others

Drive to the funeral in a separate car

Hold the service outdoors

Wear a mask

Attend by video call

Delay the memorial service, wake, or post-funeral reception

Final Takeaways

Since the beginning of the Covid-19 pandemic, everyone has had to make difficult decisions about whether or not to participate in various in-person activities. We all continue to make these tough decisions on a daily basis.

As infectious disease epidemiologists, we have discussed our decisions with each other and our colleagues. We have realized that epidemiologists make these decisions using a critical thinking approach that we realize may, at first, appear daunting. Learning to use this framework may take some time and effort, but the process will get faster and easier as you go. It is now so familiar to us, as we rely on it day in and day out. Two real-life examples from our worlds follow.

JoLynn wanted to host her neighbors at her house for a potluck. Her county was at level green, indicating that the risk of Covid-19 transmission was relatively low. However, one of her neighbors is in his 80s, so JoLynn decided that the negative consequences of Covid-19 spread were too high to justify an indoor potluck. Since she still wanted to see her friends, she adjusted the activity. Instead of having a usual potluck, everyone brought and ate their own food, and sat spaced apart outdoors.

After several months of no in-person interactions, Kristi’s teenage daughter wanted to see her friends. Their county was at level orange, indicating that the risk of Covid-19 transmission was relatively high. Even though no one in her household was at high risk for severe disease, Kristi decided that close, crowded interactions were too risky. Since it was extremely important to Kristi for her daughter to feel connected, she agreed to let her see one friend. The two girls went for a walk and agreed to stay outside, wear masks, and keep at least six feet apart at all times. Before they left for the walk, Kristi showed the girls what six feet apart looks like with two yardsticks.

We hope this framework provides clarity about how to make safer decisions in your life, and the flexibility to make adjustments that work for you. If you put some thought and creativity into how to prioritize and simplify your interactions, you may find that you feel more confident in your decisions and your pandemic life becomes a little easier. We also hope that you feel a sense of empowerment and relief knowing that you now have the tools to think critically about your actions and their impact on others.

Special thanks to Michele Jonsson Funk, PhD and R.J. Quirk, and the members of the “Public Health Rock Stars” Facebook group.