Friends, This is a case update and I’ll also talk about the new UK variant, VOC 202012/01. Wave 3b, the Thanksgiving wave, is receding, with numbers going down for the US since around the 18th. However, if Thanksgiving is an indicator, we may see a Christmas wave start this week after Christmas gatherings last week. Wave 3b was higher than 3a, but there’s no way to predict right now if a wave 3c will be higher still. The wave of new cases that began in the North this Fall is now receding for much of the country according to endcoronavirus, and the bulk of new cases are concentrated in the Southwest, East coast, and a pocket of cases in Oklahoma. LA County is continuing to experience an explosion of new cases, with 194 thousand in the past 2 weeks.
New confirmed case numbers are starting to decline for California and San Diego County as well, but again, we may see a new Christmas related wave start this week.
As we are tentatively seeing some improvement, remember that an epidemic is like a wildfire. When “containment” is achieved, diligence and caution is still warranted, since a change in the winds can cause a new flare up. We certainly saw this after Thanksgiving.
New UK variant: A new variant has arisen in the UK, perhaps in September, but began to be noticed in December. It has been given the useful but very uninteresting name of VOC 202012/01. VOC stands for “Variant of Concern”. The variant appears to have multiple mutations including one in the spike protein (N501Y) that may make it more contagious than the original version. However, it is currently thought to perhaps be slightly less virulent, but it may be too early to be sure. I have to confess that I haven’t read much primary research on it yet, and most of my current knowledge comes from radio stories and Wikipedia! I will study it more as its impact warrants!
This is a case update and I’ll also discuss recent news about vaccines and allergic reactions.Cases continue to rise dramatically in parts of the United States, particularly, the Southwest, the East Coast, and South. The Northern states, where the third wave began, are continuing to improve, some counties are getting new cases under control.
California is doing particularly badly, with the highest new case loads occurring in 5 California counties in the top 10 counties for the country. LA County alone has 170,000 active cases (new cases in the last 2 weeks), more than 3 times that of the next county, San Bernardino County.
San Diego County is in 7th place for new cases in the country with 33,000 new cases. Cases continue to increase despite new restrictions on outdoor dining.
I never go indoors without a mask on, but still frequently eat at restaurants outdoors and do a lot of hiking. I almost never wear a mask outdoors. I get tested nearly every week, and am always negative. Here in SD County, I’m noticing a lot of people wearing masks outside, and often get the stink eye from them when I’m not wearing a mask outside. Especially if there’s a breeze, I believe it is unnecessary to wear a mask on a hike! Data shows very few outbreaks occurring outside, at least in non-crowded environments. One Japanese article claimed a 19 fold smaller likelihood of becoming infected outside, and other articles saw no transmissions outdoors, according to an article in Science Magazine.
Allergic Reactions to Vaccines: As of this writing, 6 people have been reported to have suffered from severe allergic reactions after receiving a vaccine against the SARS-2 virus. This is out of 272,000 vaccinations given so far, or about 0.002% of vaccinations. The CDC has issued a guidance that those with known allergies to vaccines or injectable medications should not get vaccinated. Those with allergies to food, pets, venom, or latex are still safe to receive the SARS-2 vaccine. For those with latex allergies, know that most medical facilities have changed to non-latex gloves because of allergies to latex.
Mild allergic reactions such as site redness or pain are more common, but will resolve on there own within a day or 2.
I am currently encouraging the elderly or those with significant risk factors to get vaccinated when you can, and to inform your health care provider of your risk status so you can “get in line” for your vaccine.
Here’s an overdue case update. Cases continue to rise for the US, California, and San Diego County. The timing of the current US peak makes it clear that the bump is directly related to the Thanksgiving holiday, starting less than a week after Thanksgiving, and after cases had started to come down. LA County currently has more that 100,000 active cases, more than twice the number than the next highest county, Cook County, the home of Chicago.
More on ADE and Vaccines: Some potential very good news for me on the vaccine front. For months I’ve been warning about ADE, the phenomena that some viruses can be even more dangerous in a second infection than the first. Karen Parrott, a former colleague at Quest Diagnostics, often provides me with interesting COVID related stuff. This week she sent me a podcast featuring Paul Offit, the developer of the first Rotavirus vaccine and an author of many books on immunology and vaccine production. I am not an immunologist but he is. More importantly, he’s the first authoritative person that I’ve heard in the media speak at length on the ADE issue and how it relates to COVID. He claims in the attached clip (time stamped at 14:40) that the current vaccines do not appear to trigger the ADE pathway in animal models, and human trial subject never displayed the signs that ADE was involved in secondary exposures. This difference from SARS-1 and MERS may be related to the fact the SARS-2 is much less virulent than these other 2 viruses.
This makes me more optimistic that the vaccine will be safe from an ADE perspective. I won’t be able to get the vaccine for some time, but I am more willing to get it now than ever before. Several physicians I know are eager to get it as soon as it is available. This is great news!
In the interest of full disclosure, I will point out the some patients receiving the vaccine the UK have experienced some injection site irritation, especially in those with allergies. This is actually somewhat normal for vaccines, and appears to pass within a few days.
In addition, now that mRNA vaccines have been produced for the first time, future development of this new kind of vaccine should be even faster than this time!
Well folks, I’m disappointed to report that after a dip in cases, the confirmed case numbers are rising fast again. The timing clearly suggests that the rise in cases is related to the Thanksgiving holiday. The numbers really seem to have peaked a few weeks ago, but are back on the rise again in the US, California, and San Diego. The situation is still developing of course, so we don’t yet know how much of a rise we will see. I’m reporting this early to give you a heads up that this is happening.
Friends, This is a case update. As I suggested last week, it appears we may be past the peak of wave 3 for now. New confirmed case numbers for the US continue to trend downward, and California and San Diego County numbers appear to perhaps have peaked as well. Tammy Stevenson was right last week to point out that holiday gatherings may produce some new outbreaks. New cases don’t appear for between 5 and 20 days, so we may still see some Thanksgiving related increases, but for now, the numbers look very encouraging.
The Northern states, where the 3rd wave started, are recovering, except perhaps for Michigan and Minnesota, and the peak of the wave is moving southward. Los Angeles County now has the most new cases in the country, surpassing Cook County (Chicago). Gallatin, Madison, and Carbon counties in Montana are all past their 3rd wave peak.
Note: Since writing the above, several of my friends in the medical community have told me that they are not as optimistic as I am! While their info doesn’t contradict mine per se, they are expecting a spike in cases due to holiday gatherings. Just posting this in the interest of completeness.
This is a case update. We are continuing to see a rise in cases for the US, California, and San Diego County. However, there is a glimmer of hope. If you look carefully at the graph for the US (or just look at the red arrows), you’ll see that this Sunday’s new confirmed case number is very close to last week’s.
With numbers varying so much every day, it can be hard to see trends. But I noticed some time ago the Sunday consistently had the lowest new case numbers of the week. If a Sunday’s number was higher than the previous Sunday’s number, we would have a bad week, but if it was lower, things were getting a little better. After several weeks of steadily increasing case numbers, Sunday number suggests that we may have reached the peak of the 3rd wave. Of course, this may not pan out, and I may be apologizing later for misleading you, but it looks good right now. Also, lots of extra people are getting tested right now before Thanksgiving, which will also add to the numbers for this week.
Also notice a few more orange counties in the northern states on the map of US counties. These are likely counties where things are improving. Peaks of new cases are moving south however.
This is a case update. The US continues to see a large spike in new cases during a 3rd wave. New cases appear to be centered in the northern states and around the Great Lakes, but more southern states are now experiencing new cases as well. The county with the highest new cases right now is Cook County, the home of Chicago. New confirmed cases in the US are now double what they were during the second wave. This is all likely being driven by colder weather causing people to gather indoors.
San Diego County’s 3rd appears substantially higher than the 2nd wave. County Health reports that most known outbreaks are occurring in restaurants, especially those with bars, with the second most being businesses. The County is not reporting to the public what kind of businesses are experiencing outbreaks.
Vaccines – Because of this week’s announcement about vaccines, lots of folks are asking me about it. I’ll give you my thoughts. I am not an immunologist, I’m a molecular biologist specializing in infectious disease testing, so my thoughts on vaccines are informed, but not expert.
As I’ve discussed before, I’ve been pessimistic about COVID vaccines, mostly because of the phenomena of Antibody Dependent Enhancement, or ADE (link below). This is the phenomena in which some virus can use antibodies against a similar but not identical virus to infect the immune system and cause more severe disease. As this relates to a vaccine, a person given a vaccine could gain immunity against virus very similar to the vaccine given, but less similar strains may still infect and cause more severe illness. This has been my concern about both vaccines and the herd immunity approach.
In the past few months, however, a trickle of known cases have come out about people who have been reinfected with SARS-2. Some of these patients have had worse symptoms, and some more mild. It’s also evident that they are not being infected with the same strain they had before, but by a different strain. If all this is true, then the ADE experiment is already being done. And it looks like while some experience more severe illness, not all do, and reinfection appears to be rare, despite several circulating strains.
This week Pfizer announced that studies with their vaccine show 90% effectiveness in preventing COVID infection. My hesitation with vaccines has always been about ADE. It’s still not well known if ADE will play a significant role, but if it doesn’t, then perhaps there is reason for hope.
All medications and vaccines carry the risk of side-effects and harm. However, I’m actually becoming cautiously optimistic about a COVID vaccine.
Some technical info about vaccines. There are actually several kinds of vaccines. Various developers tried different pathways to a COVID vaccine, and several kinds are in trials right now.
Killed vaccines – These are vaccines that have been deactivated or broken down into various parts and then injected into the body. They cannot replicate and degrade in the body, so parts are attached to molecules called adjuvants that serve to boost their visibility to the immune system.
Attenuated vaccines – These are live viruses that have been engineered to cause infection, but with no or mild symptoms. Some are other viruses like Adenovirus which are symptom free, but produce viral proteins that your body can recognize and raise a response against.
RNA vaccine – This a brand new kind of vaccine that has been in testing for years. Several SARS-2 vaccines are of this kind, and are the first potential viable candidates ever. The patient is injected with a piece of RNA that codes for a viral protein. The RNA enters a cell and temporarily causes the cell to make the viral protein. RNA naturally degrades rapidly in the body and does not persist or permanently change the patient’s genetic material. This promising technique has the potential to generate new and more effective vaccines in the future.
Personally, I’m still taking a wait and see approach. Vaccines will probably not be available to the general public for few months. By then we may know more about how people are responding.
Note, March 26th, 2022: The first part of this post was written on July 7th, 2020. Since that time, there has been evidence that appears contradictory in the ADE story. Reading the entire post will help you understand how ADE and COVID are related, but it is a complex and evolving issue, so things may still change.
Originally posted July 7th, 2020
I’m going to bring up an issue that I’ve been avoiding talking about for some time. I’ve been avoiding talking about it because it’s not a certainty, and also because the possibility will be scary for some. The reason I feel compelled to talk about it now is that many are having a hard time understanding why I am still so concerned about the virus when the fatality rate is low and dropping, and folks want to get back to normal life. I’m even hearing about young people having COVID parties in which people gather with a sick individual so they can all get infected and be immune from the virus thereafter.
Before I share this, I’ll also say that the medical community is doing a better job treating patients with COVID, and the disease is becoming more survivable. In addition, we now know a lot about how the virus is spread, and if a person wants to remain uninfected, they can do that, while still getting together with friends and family, and still working and getting on with life. You can be reasonably certain you will not get infected if you do the following:
1) Wear a mask or face covering in public. Avoid places with unmasked people. 2) Keep 6 ft away from others. 3) Avoid indoor gatherings, especially ones in which singing or shouting is likely. 4) Small outdoor gatherings are fine, even without masks, if everyone maintains a distance. Have guests bring their own food. 5) While many restaurants are open for limited indoor seating, I personally am still not comfortable eating indoors at a restaurant. I enjoy eating outdoors at restaurants, however.
Antibody Dependent Enhancement: Several years ago, scientists were developing a vaccine against Dengue Fever, a mosquito borne disease which causes debilitating joint pain in patients. Some time after trial vaccination, several vaccinated patients died suddenly of Dengue Fever. This became the most studied example of Antibody Dependent Enhancement (ADE). Normally, for the annual flu let’s say, a person gets infected by the flu, is sick for a few days, and the immune system develops a response by creating antibodies against that specific strain of the flu. If they are exposed again in a month, nothing will happen. If the patient is exposed to a different strain the following year, they may still get sick, but the antibodies they developed the year before may help them have less severe disease and recover more quickly. Part of the immune response is that some immune cells display antibodies on their surface to capture new invaders.
With Dengue and some other viruses, the first stages are normal. A person gets infected and develops a response. If they get re-infected a month later, nothing happens. But if they get infected with a slightly different strain months or years later, instead of being protected, the virus attaches to antibodies displayed on immune cells and uses the antibodies as a site of entry into the immune system. The immune system is quickly infected, and the patient has a more severe disease with the second infection. Some estimates are that disease may be 3-4 x more severe in these patients.
As it turns out, SARS-1, which arose in 2002, and MERS, which has small outbreaks every year, are both Coronaviruses and both appear to be able to use the ADE pathway. This raises the possibility that SARS-2, the current virus, can also use the ADE pathway. This means that a person infected for a second time with a different strain of SARS-2, or any other Coronavirus for that matter, may be at much higher risk for severe disease.
This is why I’m not in favor of pursuing herd immunity as a pathway out of this crisis, because it will prime people for ADE related problems if a similar strain should strike next year.
This is not a new idea. If you search for “ADE” or “Antibody Dependent Enhancement”, you will see many articles, some peer reviewed from respected journals, on the phenomena. Dr. Fauci has even referenced it using the term “enhancement” when talking about vaccine development.
Why haven’t the government public health departments been more open about this? They tend to make statements only based on what they can be reasonably certain of, which is why they have been so slow to react to many aspects of the current crisis.
Again, it’s not certain that ADE will play a role next year. It’s too early to know. I’m informing you of the possibility so you can make wise decisions for you and your family.
_________________________________________ Update: November 20, 2020
Since writing the above post, things have changed a little. There have been a handful of known cases of people being re-infected with SARS-2. In some of these patients, symptoms were worse, while in others, symptoms were less severe. In all of the well characterized cases, the 1st and 2nd strains that infected them were different, suggesting that it’s not a re-infection by the same strain, but a new infection by a different strain.
We’ve had at least 2 main strains in the US, SARS-2 which arrived in January or February, and a strain called D614G which probably arrived in April or May and likely caused the 2nd wave in June and July. The D614G strain is likely more infectious than the original SARS-2 strain, but is perhaps less virulent, since the fatality rate during the second wave appears to have been lower. In fact, there may have been several strains circulating around the world and the US for much of the pandemic.
How does this all relate to ADE? The fear with ADE is that a 2nd infection will cause worse symptoms than with the first infection. This may still be true. But we’ve had several circulating strains and so far, no real evidence the re-infections have universally been worse. So it appears for now that the ADE experiment is already going on, and that perhaps the phenomena will not have as great an impact as I feared. I am currently cautiously optimistic that ADE will not cause significant additional mortality.
This also has some impact on the vaccine discussion that is currently ongoing. If ADE will not have a significant impact, than the vaccine may be safer that I previously thought, and I have become cautiously optimistic about the success of the vaccine.
More on ADE and Vaccines: Some potential very good news for me on the vaccine front. For months I’ve been warning about ADE, the phenomena that some viruses can be even more dangerous in a second infection than the first. Karen Parrott, a former colleague at Quest Diagnostics, often provides me with interesting COVID related stuff. This week she sent me a podcast featuring Paul Offit, the developer of the first Rotavirus vaccine and an author of many books on immunology and vaccine production. I am not an immunologist but he is. More importantly, he’s the first authoritative person that I’ve heard in the media speak at length on the ADE issue and how it relates to COVID. He claims in the attached clip (time stamped at 14:40) that the current vaccines do not appear to trigger the ADE pathway in animal models, and human trial subjects never displayed the signs that ADE was involved in secondary exposures. This difference from SARS-1 and MERS may be related to the fact the SARS-2 is much less virulent than these other 2 viruses.
This makes me more optimistic that the vaccine will be safe from an ADE perspective. I won’t be able to get the vaccine for some time, but I am more willing to get it now than ever before. Several physicians I know are eager to get it as soon as it is available. This is great news!
In the interest of full disclosure, I will point out the some patients receiving the vaccine the UK have experienced some injection site irritation, especially in those with allergies. This is actually somewhat normal for vaccines, and appears to pass within a few days.
Now that mRNA vaccines have been produced for the first time, future development of this new kind of vaccine should be even faster than this time!
________________________________________________ Update: April 13th 2021
ADE and the next SARS virus: I wanted to explain a little more about my continued concerns about ADE. As the pandemic progresses and we have numerous variants circulating around the world and the US, ADE does not appear to have had an impact on the current situation. This is certainly good news. If it did have an impact, we would be seeing additional deaths from the new variants, which we do not.
My continued concern comes because ADE impacts our ability to fight the NEXT virus. SARS viruses (SARS, MERS, SARS-2) have the ability to easily infect the immune systems of those previously infected with closely related but different strain of the virus. If a future strain of SARS comes out, let’s call it SARS-3 for now, ADE may become a big deal. I stress that this is only theoretical at this point. SARS was moderately infectious, but also very pathogenic, giving all known patients severe symptoms and killing 10%. It was actually less dangerous globally, since outbreaks tended to be detected early and quickly snuffed out. SARS-2 is highly infectious, but much less pathogenic. It’s greater global impact came from it’s very high infectiousness and very long incubation time, being passed even from pre-symptomatic patients. The tendency of all viruses is to become more infectious and less pathogenic over time, a pattern followed by SARS and SARS-2. If we have a SARS-3 someday, it will likely be even more infectious than SARS-2, but less pathogenic. On the other hand, MERS is more pathogenic than SARS, so this pattern doesn’t always follow. The next time another SARS coronavirus breaks out, we will need to be very careful initially until we understand the parameters of the new virus.
So what do you do if you had COVID or had a COVID vaccine if a SARS-3 comes out? If that happens, vaccine production will likely be much faster than this time. Be very careful with the virus initially, and get the new vaccine as soon as it is available to you, because you may be at greater risk for severe symptoms. I know some of this is confusing and counter-intuitive! Feel free to ask questions below!
Delta already using the ADE pathway? A doctor friend of mine sent me a pre-print paper from a lab in Japan. Please note, this is a pre-print paper and has not yet finished peer review! The paper describes experiments using antibodies derived from patients infected with the Wuhan strain, as well as with the Delta Variant. They then studied binding of these antibodies to artificial viruses. The paper argues that Delta variant viruses are less neutralized by vaccines against “wild-type” or Wuhan strain vaccines. While the “wild-type” antibodies against Wuhan can neutralize a region of the Delta Spike protein called the Receptor Binding Domain (RBD) (Figure 1C), other antibodies binding to another region of Delta Spike protein actually enhance infectivity. Figure 1D from the paper shows negative levels of “neutralization” for antibodies that bind the N-terminal domain of the Spike protein. The paper calls this “enhanced”. Yes, this is the ADE I’ve been talking about.
They suggest that with rapid changes in COVID variants, a new version of Delta is going to be able to use the ADE pathway in the near future, when Wuhan era antibodies will no longer be able to neutralize a mutated Delta strain.
To sum that all up in simpler language, it basically says that Delta is more infectious because it is partially using the ADE method of infection. Future versions may be less prone to be neutralized by Wuhan antibodies, making them fully enhanced. If this happens, we may have more severe disease in those who get infected with this new enhanced Delta.
They conclude by saying a booster against the Wuhan strain will not be effective in improving protection from Delta, and that a new vaccine against Delta will be required.
The material in the paper may help to explain why we have been seeing lowering levels of vaccine effectiveness in some countries.
Just to be very clear, they are not saying that this new enhanced Delta exists now, just that it may exist in the future.
I will pay close attention to this issue. If you have already been vaccinated or had COVID, a new Delta vaccine will be your best defense against possible ADE arising from a possible enhanced Delta.
If an enhanced Delta arises, and you have had Wuhan COVID or a Wuhan vaccine, and you haven’t had Delta, then you may be at greater risk for severe disease.
If you have had COVID since July 2021, you are likely already immune to the Delta variant, and this will not be an issue for you.
I am fully aware this complicated. Also, the CDC has rarely if ever discussed this possibility, so unfortunately, most of the people you talk to about this will not believe it. I am sharing this with you so you can make wise decisions for you and your family.
Some companies are already working on Delta versions of the vaccine. If you have had the current vaccines, or had COVID, you should get the Delta vaccines as soon as they are available.
Of course, discuss your medical history with your doctor before making medical decisions.
The “Final” Verdict on Antibody Dependent Enhancement: As most of you know, ADE has been a major concern of mine from almost the beginning. I’m finally willing to give an assessment of how ADE impacted the pandemic. There were a smattering of cases in previously infected people who may have had more severe cases because of possible ADE, but not more than a smattering. It’s also becoming well acknowledged that Omicron infected everyone regardless of vaccination status and may have even preferentially infected vaccinated people. I know MANY people who are double vaxxed and boosted who got Omicron.
All that being said, I never saw any evidence that conclusively suggested that ADE was causing more severe symptoms because of natural or vaccine mediated immunity. In fact, even during Omicron, during which ADE was most likely to be operating, those with previous immunity clearly fared better than those without. Because I think Omicron is the death rattle of the pandemic, I’m willing to say that ADE never became the threat I was concerned about. For this reason, IF I didn’t already have natural immunity because of Omicron, I might actually get vaccinated IF I could find someone who would aspirate before injecting (see the post from earlier this week)!
I never saw any paper that dealt with the issue of ADE, not even a little. Those that mentioned it did so only in passing. __________________________________ Updated March 25, 2022
Certain vaccinated individuals are more likely to be infected by Omicron than the unvaccinated: A UK surveillance report shows that vaccine effectiveness against symptomatic Omicron infection goes from around 65% effective soon after 2 doses of vaccine, to around 5% 6 months later. Protection from hospitalization goes down to just 35% after 6 months. These findings suggest that to maintain full protection against Omicron, a vaccinated person will need to get a booster every 3 to 6 months.
From UK Surveillance Report, March 17, 2022, Table 1b. Effectiveness of Pfizer vaccine at preventing symptomatic COVID infection after 2 doses, and after a Pfizer or Moderna booster.From UK Surveillance Report, March 17, 2022, Table 2b. Effectiveness of Pfizer vaccine at preventing hospitalization after 2 doses, and after a Pfizer or Moderna booster.
In another finding from the report, people with 3 doses of vaccine are 3x more likely to be infected with Omicron than unvaccinated individuals. This is the clearest evidence yet that Omicron may be using Antibody Dependent Enhancement (ADE) to infect people. The Lewnard et al paper from a few months ago has a similar finding. For both studies, a certain number of vaccine doses are more likely to increase the chance of infection. If viruses are using the ADE pathway, this effect would be explained more by the timing than by the number of doses per se. For ADE to work, a person needs to have a mediocre immune response to an agent, not a strong or weak one. Since we know vaccine mediated immunity goes down over time, then a person becomes more likely to be reinfected as their immune response goes from strong to mediocre.
From UK Surveillance Report, March 17, 2022, Table 13. New case rates among UK residents with at least 3 doses of vaccine, and with no vaccination. Numbers are normalized for the percentage of people in each group.
So should you get a booster? Again, if you have risk factors like age, obesity or respiratory problems, you might want to get a booster every 3 – 6 months. Otherwise, you may choose instead to just take extra precautions as Omicron cases continue to fall in the US. If you choose to get a booster, ask them to aspirate before injection. Talk to your doctor when making medical decisions.
This is a case update. The US is experiencing a third peak in cases. This is likely being driven by cold weather, driving people indoors where the virus spreads more easily. The 3rd peak is already almost 2x as high as the 2nd peak in July and August, and it’s still going up fast. Some states are experiencing record hospitalizations.
California has been trending up for the last several weeks, and San Diego is trending up this week for the second week since the 3rd wave began.
Graph is by me, from data collected from Johns Hopkins University COVID site.Graph is by me, from data collected from Johns Hopkins University COVID site. “Active Confirmed Cases” numbers are calculated based on the assumption that patients confirmed to have SARS-2 virus at least 17 days ago have recovered.Graph is by me, from data collected from San Diego County Public Health. See also regularly updated slides from SD County.Graph is by me, from data collected from San Diego County Public Health. See also regularly updated slides from SD County. “Active Confirmed Cases” numbers are calculated based on the assumption that patients confirmed to have SARS-2 virus at least 17 days ago have recovered.
I been seeing new ads in California, talking about benefits of mask wearing. The ads have several shots of people wearing masks in small groups outdoors. As you know, I am a big fan of masks in indoors environments, and wear a mask a lot when at work in a lab or when traveling. However, wearing a mask outdoors is almost always unnecessary unless you are in a large group of people. I’m am not saying that you should ignore local guidance if they require mask wearing outdoors! I am saying, however, that as far as getting infected is concerned, you don’t need to wear a mask while you’re jogging, hiking, or riding a bike.
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